1417190539 NPI number — CHICAGO CONSERVATIVE CARE, INC.

Table of content: JIMMY STEVEN VAN SCHUYVER RN (NPI 1740003169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417190539 NPI number — CHICAGO CONSERVATIVE CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHICAGO CONSERVATIVE CARE, INC.
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:
1417190539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1706 W NORTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60622-2125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1706 W NORTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-697-8088
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HOBERLAND
Authorized Official First Name:
OTYLIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-697-8088

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038.011340 , 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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