Provider Demographics
NPI:1396155156
Name:PEDIATRIC FUNDAMENTALS,LLC
Entity type:Organization
Organization Name:PEDIATRIC FUNDAMENTALS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAUNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUZICH
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:815-931-8595
Mailing Address - Street 1:36963 IRISH LN
Mailing Address - Street 2:
Mailing Address - City:CUSTER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60481-8420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36963 IRISH LN
Practice Address - Street 2:
Practice Address - City:CUSTER PARK
Practice Address - State:IL
Practice Address - Zip Code:60481-8420
Practice Address - Country:US
Practice Address - Phone:815-931-8595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146006731235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty