1174525422 NPI number — PROVIDENCE OPERATIONS, LLC

Table of content: (NPI 1174525422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174525422 NPI number — PROVIDENCE OPERATIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE OPERATIONS, 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:
6
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:
1174525422
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18601 N CREEK 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:
60477-6397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-342-8100
Provider Business Mailing Address Fax Number:
708-342-8006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13259 S CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALOS HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60463-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-597-1000
Provider Business Practice Location Address Fax Number:
708-597-1000
Provider Enumeration Date:
06/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ZANDSTRA
Authorized Official First Name:
JOHANNA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
COMPLIANCE OFFICER
Authorized Official Telephone Number:
708-342-8137

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0028605 , 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: 362382853002 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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