1255354635 NPI number — OPEN DOOR CLINIC OF GREATER ELGIN

Table of content: (NPI 1255354635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255354635 NPI number — OPEN DOOR CLINIC OF GREATER ELGIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPEN DOOR CLINIC OF GREATER ELGIN
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:
1255354635
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1665 LARKIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELGIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60123-5977
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-695-1093
Provider Business Mailing Address Fax Number:
847-695-0501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
164 DIVISION ST
Provider Second Line Business Practice Location Address:
# 607
Provider Business Practice Location Address City Name:
ELGIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60120-5587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-695-1093
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAINES
Authorized Official First Name:
LA JUAN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
847-695-1093

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com