Provider Demographics
NPI:1437131497
Name:SPORTHO PHYSICAL AND AQUATIC THERAPY, LLC
Entity type:Organization
Organization Name:SPORTHO PHYSICAL AND AQUATIC THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAPRARO
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:773-586-2768
Mailing Address - Street 1:6921 W ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2319
Mailing Address - Country:US
Mailing Address - Phone:773-586-2768
Mailing Address - Fax:773-586-2780
Practice Address - Street 1:6921 W ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2319
Practice Address - Country:US
Practice Address - Phone:773-586-2768
Practice Address - Fax:773-586-2780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400239582Medicare PIN
ILK11952Medicare UPIN
ILF400095649Medicare PIN
IL210248Medicare PIN
ILK11950Medicare UPIN
ILK11954Medicare UPIN