1134212665 NPI number — KANKAKEE VALLEY OB/GYN,LLC

Table of content: MR. LUIS FERNANDO ESTRADA MS, MSW (NPI 1730792920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134212665 NPI number — KANKAKEE VALLEY OB/GYN,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KANKAKEE VALLEY OB/GYN,LLC
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:
1134212665
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
375 N WALL STREET
Provider Second Line Business Mailing Address:
SUITE P630
Provider Business Mailing Address City Name:
KANKAKEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-933-4510
Provider Business Mailing Address Fax Number:
815-933-4259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 N WALL STREET
Provider Second Line Business Practice Location Address:
SUITE P630
Provider Business Practice Location Address City Name:
KANKAKEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-933-4510
Provider Business Practice Location Address Fax Number:
815-933-4259
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MEHTA
Authorized Official First Name:
TAPAN
Authorized Official Middle Name:
ASHVIN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-933-4510

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 173000000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04628061 . This is a "BC/BS PROVIDER #" identifier . This identifiers is of the category "OTHER".




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