1467761312 NPI number — PARK LAWN CENTER

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 1467761312 NPI number — PARK LAWN CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARK LAWN CENTER
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:
1467761312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5831 W 115TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALSIP
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60803-5150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-396-1117
Provider Business Mailing Address Fax Number:
708-396-1186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10833 LAPORTE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK LAWN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60453-5412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-425-3344
Provider Business Practice Location Address Fax Number:
708-425-3530
Provider Enumeration Date:
09/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WEISE
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
708-425-3344

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  0027078 , 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: 0027078 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com