Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 070.019110 | IL |
NPI | 1003196593 |
---|---|
Provider Name | Mr. Kendrick Dwayne Summers |
First Address | Chicago, IL 60611-2987 |
Second Address | Chicago, IL 60611-2987 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2011 |
Last Update Date | 30/06/2021 |