Provider Demographics
NPI:1053927640
Name:MOOSE PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:MOOSE PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CALAME
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:309-670-0853
Mailing Address - Street 1:2000 W PIONEER PKWY STE 22
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-5805
Mailing Address - Country:US
Mailing Address - Phone:309-670-0853
Mailing Address - Fax:309-279-5211
Practice Address - Street 1:2000 W PIONEER PKWY STE 22
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-5805
Practice Address - Country:US
Practice Address - Phone:309-670-0853
Practice Address - Fax:309-279-5211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-18
Last Update Date:2021-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty