1386028835 NPI number — THE DUBOIS DOUGLAS CENTRES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386028835 NPI number — THE DUBOIS DOUGLAS CENTRES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE DUBOIS DOUGLAS CENTRES
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:
1386028835
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4747 LINCOLN MALL DR
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
MATTESON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60443-3811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-283-0886
Provider Business Mailing Address Fax Number:
708-283-0895

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4747 LINCOLN MALL DR
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
MATTESON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60443-3811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-283-0886
Provider Business Practice Location Address Fax Number:
708-283-0895
Provider Enumeration Date:
07/15/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINS-MENSAH
Authorized Official First Name:
MARCEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
708-283-0886

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  199500004C , 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)





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