Provider Demographics
NPI:1124065743
Name:KIRK CENTER FOR HEALTHY LIVING, PC
Entity type:Organization
Organization Name:KIRK CENTER FOR HEALTHY LIVING, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:708-301-3102
Mailing Address - Street 1:14815 FOUNDERS XING
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-6705
Mailing Address - Country:US
Mailing Address - Phone:708-301-3102
Mailing Address - Fax:708-301-4450
Practice Address - Street 1:14815 FOUNDERS XING
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-6705
Practice Address - Country:US
Practice Address - Phone:708-301-3102
Practice Address - Fax:708-301-4450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932478OtherBLUE CROSS BLUE SHIELD
IL214552Medicare ID - Type UnspecifiedFACILITY NUMBER
ILK34025Medicare UPIN