Provider Demographics
NPI:1427712389
Name:PHYSICAL WELLNESS LAB, LLC
Entity type:Organization
Organization Name:PHYSICAL WELLNESS LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATE
Authorized Official - Middle Name:NUGENT
Authorized Official - Last Name:SHEAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:312-925-5325
Mailing Address - Street 1:1208 E LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2265
Mailing Address - Country:US
Mailing Address - Phone:312-925-5325
Mailing Address - Fax:
Practice Address - Street 1:1300 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3200
Practice Address - Country:US
Practice Address - Phone:224-765-1598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-27
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty