Provider Demographics
NPI:1053873513
Name:PANOPTIC PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:PANOPTIC PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:LUKE
Authorized Official - Last Name:PANOZZO
Authorized Official - Suffix:JR
Authorized Official - Credentials:SLP
Authorized Official - Phone:815-513-3298
Mailing Address - Street 1:1802 NORTH DIVISION STREET, SUITE 202
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450
Mailing Address - Country:US
Mailing Address - Phone:815-513-3298
Mailing Address - Fax:815-513-5446
Practice Address - Street 1:1511 N CONVENT ST STE 1000
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1497
Practice Address - Country:US
Practice Address - Phone:815-401-5102
Practice Address - Fax:815-401-5103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-03
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty