Provider Demographics
NPI:1124527650
Name:COMBENIDO, JOREK BORDAS
Entity type:Individual
Prefix:
First Name:JOREK
Middle Name:BORDAS
Last Name:COMBENIDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4265 N MOBILE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-1585
Mailing Address - Country:US
Mailing Address - Phone:224-703-4949
Mailing Address - Fax:
Practice Address - Street 1:4340 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2121
Practice Address - Country:US
Practice Address - Phone:773-545-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-11
Last Update Date:2018-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022771225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist