1992747505 NPI number — PROCARE 4268 YANKEE, L.L.C.

Table of content: (NPI 1992747505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992747505 NPI number — PROCARE 4268 YANKEE, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROCARE 4268 YANKEE, L.L.C.
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:
1992747505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 S MICHIGAN AVE
Provider Second Line Business Mailing Address:
SUITE 619
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60603-5902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-252-7204
Provider Business Mailing Address Fax Number:
312-332-6140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 S MICHIGAN AVE
Provider Second Line Business Practice Location Address:
SUITE 619
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60603-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-252-7204
Provider Business Practice Location Address Fax Number:
312-332-6140
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAURICIO
Authorized Official First Name:
CRISTIANA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, PHARMACY ENROLLMENTS
Authorized Official Telephone Number:
401-765-1500

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  054015141 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 054015141 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 054015141 , 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: 200326858001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 054015141 . This is a "RESIDENT STATE LICENSE #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1476820 . This is a "COMMERCIAL NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 320008059 . This is a "RESIDENT STATE C/S LIC #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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