Provider Demographics
NPI:1992821110
Name:AMANDA AREVALO, P.C.
Entity type:Organization
Organization Name:AMANDA AREVALO, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:AREVALO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-602-1581
Mailing Address - Street 1:PO BOX 1651
Mailing Address - Street 2:
Mailing Address - City:NORTH RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-0951
Mailing Address - Country:US
Mailing Address - Phone:708-602-1581
Mailing Address - Fax:
Practice Address - Street 1:6915 30TH PL
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2957
Practice Address - Country:US
Practice Address - Phone:708-602-1581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1634441OtherBLUE CROSS BLUE SHIELD IL