1225338379 NPI number — MANUEL O ROJAS

Table of content: (NPI 1225338379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225338379 NPI number — MANUEL O ROJAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANUEL O ROJAS
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:
MANUEL O ROJAS
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:
1225338379
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4254 W 55TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60632-4642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-582-5200
Provider Business Mailing Address Fax Number:
773-582-2772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4254 W 55TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60632-4642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-582-5200
Provider Business Practice Location Address Fax Number:
773-582-2772
Provider Enumeration Date:
10/22/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROJAS
Authorized Official First Name:
MANUEL
Authorized Official Middle Name:
O
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
773-582-5200

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  036049646 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X , with the licence number: 036103907 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: 036117332 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 036049646 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036117332 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036103907 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".