Provider Demographics
NPI:1053557264
Name:GOODLIFE PHYSICAL THERAPY
Entity type:Organization
Organization Name:GOODLIFE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRAB
Authorized Official - Middle Name:MICKEY
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:708-966-4386
Mailing Address - Street 1:9730 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2814
Mailing Address - Country:US
Mailing Address - Phone:708-581-9700
Mailing Address - Fax:
Practice Address - Street 1:16517 106TH CT
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-4545
Practice Address - Country:US
Practice Address - Phone:708-966-4386
Practice Address - Fax:708-966-4387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-013727225100000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy