1568903300 NPI number — AGNIESZKA BORUC N.P.

Table of content: LULANI MATA SLP (NPI 1497165906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568903300 NPI number — AGNIESZKA BORUC N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BORUC
Provider First Name:
AGNIESZKA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

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:
1568903300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1851 SILVER CROSS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LENOX
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-300-3080
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18350 KEDZIE AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
HOMEWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60430-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-365-1055
Provider Business Practice Location Address Fax Number:
708-799-1249
Provider Enumeration Date:
03/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  209.015736 , 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)





Copyright © 2007-2025 www.npivalidator.com