Provider Demographics
NPI:1053365403
Name:YORKVILLE PHYSICAL THERAPY AND SPORTS MEDICINE CENTER, LLC
Entity type:Organization
Organization Name:YORKVILLE PHYSICAL THERAPY AND SPORTS MEDICINE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:630-978-6218
Mailing Address - Street 1:1900 OGDEN AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4273
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 OGDEN AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4273
Practice Address - Country:US
Practice Address - Phone:630-553-0349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210668Medicare PIN