Provider Demographics
NPI:1861421950
Name:CHICAGO HEALTH AND PHYSICAL THERAPY CENTER SC
Entity type:Organization
Organization Name:CHICAGO HEALTH AND PHYSICAL THERAPY CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIETZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-282-6648
Mailing Address - Street 1:5545 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1331
Mailing Address - Country:US
Mailing Address - Phone:773-282-6648
Mailing Address - Fax:773-282-6965
Practice Address - Street 1:5545 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1331
Practice Address - Country:US
Practice Address - Phone:773-282-6648
Practice Address - Fax:773-282-6965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042.618903261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213847Medicare PIN