Basic Information
| Provider Information | |||||||||
| NPI: | 1669878500 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEAM REHABILITATION IL03 LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33900 HARPER AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480354258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864169100 | ||||||||
| FaxNumber: | 5864169103 | ||||||||
| Practice Location | |||||||||
| Address1: | 1226 OGDEN AVE | ||||||||
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| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605152740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305604855 | ||||||||
| FaxNumber: | 3312516943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2014 | ||||||||
| LastUpdateDate: | 01/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | ROONEY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5864169100 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TEAM REHABILIATION SERVICES, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.