Provider Demographics
NPI:1871713552
Name:N SHORE SPINAL & SPORTS REHAB LTD
Entity type:Organization
Organization Name:N SHORE SPINAL & SPORTS REHAB LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-295-0920
Mailing Address - Street 1:100 E SCRANTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2530
Mailing Address - Country:US
Mailing Address - Phone:847-295-0920
Mailing Address - Fax:847-295-5214
Practice Address - Street 1:100 E SCRANTON AVE
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-2530
Practice Address - Country:US
Practice Address - Phone:847-295-0920
Practice Address - Fax:847-295-5214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042007526111NX0800X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID #
IL561710Medicare ID - Type UnspecifiedFACILITY #