Provider Demographics
NPI:1366728560
Name:IN-HOME PHYSICAL THERAPY AND WELLNESS, LLC
Entity type:Organization
Organization Name:IN-HOME PHYSICAL THERAPY AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GAMBOA
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:1217-653-6814
Mailing Address - Street 1:7 MILLBROOK CT
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-2542
Mailing Address - Country:US
Mailing Address - Phone:217-653-6814
Mailing Address - Fax:877-482-0929
Practice Address - Street 1:7 MILLBROOK CT
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-2542
Practice Address - Country:US
Practice Address - Phone:217-653-6814
Practice Address - Fax:877-482-0929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-01
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL6887OtherMEDICARE PTAN