Organization
INNOVATIVE PEDIATRICS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BRYAN DAVID MATTSON OTR (LLC MANAGER)
(773) 968-7871
Entity
Organization
Contact information
Practice address
1048 W LAWRENCE AVE, #1, CHICAGO, IL 60640-6544
(773) 968-7871
(773) 561-6815
Mailing address
PO BOX 408799, CHICAGO, IL 60640-8799
(773) 968-7871
Taxonomy
Speciality
Code
Description
License number
State
225XP0200X
Pediatric Occupational Therapist
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01628182
IL BLUE CROSS PROVIDER #
IL
Enumeration date
01/29/2007
Last updated
02/06/2008
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