1154509289 NPI number — ST. COLETTA'S OF ILLINOIS, INC.

Table of content: (NPI 1154509289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154509289 NPI number — ST. COLETTA'S OF ILLINOIS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. COLETTA'S OF ILLINOIS, INC.
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:
COUNTRY CLUB TERRACE
Provider Other Organization Name Type Code:
3
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:
1154509289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18350 CROSSING DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TINLEY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60487-6294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-342-5200
Provider Business Mailing Address Fax Number:
708-429-7021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4900 183RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNTRY CLUB HILLS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60478-4568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-647-0752
Provider Business Practice Location Address Fax Number:
708-342-2579
Provider Enumeration Date:
01/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SKAFGAARD
Authorized Official First Name:
ANNETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
708-342-5253

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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