1679907463 NPI number — MIDWAY MEDIATION & COACHING SERVICES, LLC

Table of content: (NPI 1679907463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679907463 NPI number — MIDWAY MEDIATION & COACHING SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWAY MEDIATION & COACHING SERVICES, 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:
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:
1679907463
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1160 STARWOOD PASS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE IN THE HILLS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60156-4890
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-852-0499
Provider Business Mailing Address Fax Number:
815-477-2270

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 CRYSTAL POINT DR
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
CRYSTAL LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-852-0499
Provider Business Practice Location Address Fax Number:
815-477-2287
Provider Enumeration Date:
08/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
847-852-0499

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149011403 , 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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