Provider Demographics
NPI:1386784098
Name:BETTENDORF, CAROL (PT)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BETTENDORF
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-0764
Mailing Address - Country:US
Mailing Address - Phone:847-265-7300
Mailing Address - Fax:847-265-7301
Practice Address - Street 1:89 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-8411
Practice Address - Country:US
Practice Address - Phone:847-265-7300
Practice Address - Fax:847-265-7301
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070002049174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04932271OtherBLUE SHIELD
IL710957905OtherFEIN