1710234919 NPI number — GOLDEN QUALITY MEDICAL SERVICE

Table of content: (NPI 1710234919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710234919 NPI number — GOLDEN QUALITY MEDICAL SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN QUALITY MEDICAL SERVICE
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:
1710234919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9035 S BURLEY
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:
60617-4460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
872-800-8241
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9035 S BURLEY AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60617-4460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
872-800-8241
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDEN WOODS
Authorized Official First Name:
WANDA
Authorized Official Middle Name:
FAYE
Authorized Official Title or Position:
PHLEBOTOMIST /EKG TECH
Authorized Official Telephone Number:
872-800-8241

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , 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