| Organization Name: | SUPPLEMENTAL |
| NPI Number: | 1316294507 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DAWN T AVITT (PTA) |
| Mailing Address: | 152 S Walker St Braidwood |
| State: | IL US |
| Postal Code: | 604081952 |
| Phone Number: | 8154582492 |
| Fax Number: | |
| NPI Enumeration Date: | 08/07/2012 |
| NPI Last Update Date: | 08/07/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2000X |
| License Number: | 160.003259 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Physical Therapy |
| Taxonomy Definition: | |