Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist |
NPI | 1003262320 |
---|---|
Provider Name | Mark Gore |
First Address | Des Plaines, IL 60016-2359 |
Second Address | Glenview, IL 60025-7645 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/05/2016 |
Last Update Date | 05/05/2016 |