1457573099 NPI number — NICASA

Table of content: (NPI 1457573099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457573099 NPI number — NICASA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NICASA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457573099
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31979 N FISH LKAE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROUND LAKE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-546-6450
Provider Business Mailing Address Fax Number:
847-546-6760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31979 N FISH LKAE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROUND LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-546-6450
Provider Business Practice Location Address Fax Number:
847-546-6760
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
847-546-6450

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  CA06140005A , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CA06140002A , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA06140005A , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: A06140005A . This is a "STATE OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: A06140004A . This is a "STATE OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CA06140001A , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: A06140003A . This is a "STATE OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: A06140001A . This is a "STATE OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: A06140002A . This is a "STATE OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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