Provider Demographics
NPI:1154900553
Name:PHYSIO PR, PLLC
Entity type:Organization
Organization Name:PHYSIO PR, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELUSEGUN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLOPO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:773-556-8569
Mailing Address - Street 1:900 W MARGATE TER APT 1C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3824
Mailing Address - Country:US
Mailing Address - Phone:773-556-8569
Mailing Address - Fax:
Practice Address - Street 1:900 W MARGATE TER APT 1C
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3824
Practice Address - Country:US
Practice Address - Phone:773-556-8569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty