MEDICARE: PMR ILLINOIS HOLDING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1013520113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PMR ILLINOIS HOLDING, LLC

Provider Business Mailing Address
First Line	:	1395 NW 167TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-5710
Country	:	US
Telephone Number	:	305-628-6117
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 E SIBLEY BLVD
Second Line	:
City	:	DOLTON
State	:	IL
Zip	:	60419-2599
Country	:	US
Telephone Number	:	708-340-7400
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MARY CHEN
Credential	:
Telephone Number	:	305-831-4722

Provider Enumeration Date	:	08/28/2020
Last Update Date	:	10/31/2024

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