1760470553 NPI number — ALDEN OF WATERFORD, L.L.C.

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 1760470553 NPI number — ALDEN OF WATERFORD, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALDEN OF WATERFORD, L.L.C.
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:
1760470553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4200 W PETERSON AVE
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60646-6074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-286-6622
Provider Business Mailing Address Fax Number:
773-286-2150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 RANDI DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60504-4758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-851-7266
Provider Business Practice Location Address Fax Number:
630-851-7585
Provider Enumeration Date:
10/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SCHLOSSBERG
Authorized Official First Name:
FLOYD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-286-6622

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0042036 , 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)

  • Identifier: 50214 . This is a "BLUE CROSS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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