1558724039 NPI number — TEILA DESARNO L.C.P.C., C.A.D.C.

Table of content: (NPI 1558422857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558724039 NPI number — TEILA DESARNO L.C.P.C., C.A.D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESARNO
Provider First Name:
TEILA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.C.P.C., C.A.D.C.
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:
1558724039
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
795 OREGON TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSELLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60172-1306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-825-8745
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 DUNHAM RD
Provider Second Line Business Practice Location Address:
SUITE 55
Provider Business Practice Location Address City Name:
ST CHARLES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60174-1490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-825-8745
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2016

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: 101YA0400X , with the licence number:  30153 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 180.007855 , 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