Basic Information
| Provider Information | |||||||||
| NPI: | 1720170384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AQUISAP | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 972 BROOK FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | SHOREWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604318807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154394938 | ||||||||
| FaxNumber: | 8154397816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070-014719 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00931563 | 01 | IL | MEDICARE RAILROAD | OTHER |