1609168657 NPI number — NEW LIFE PENTECOSTAL MEDICAL CLINIC FOR THE UNINSURED INC

Table of content: (NPI 1609168657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609168657 NPI number — NEW LIFE PENTECOSTAL MEDICAL CLINIC FOR THE UNINSURED INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW LIFE PENTECOSTAL MEDICAL CLINIC FOR THE UNINSURED 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:
6
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:
1609168657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
183 N SCHUYLER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANKAKEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60901-3828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-304-4305
Provider Business Mailing Address Fax Number:
815-304-4306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
183 N SCHUYLER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANKAKEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60901-3828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-304-4305
Provider Business Practice Location Address Fax Number:
815-304-4306
Provider Enumeration Date:
05/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GARCIA
Authorized Official First Name:
OMAR
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
815-304-4305

Provider Taxonomy Codes

  • Taxonomy code: 2083X0100X , with the licence number:  036.124389 , 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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