Healthcare Provider Details

I. General information

NPI: 1881245314
Provider Name (Legal Business Name): VITALISCARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 E ALGONQUIN RD
ALGONQUIN IL
60102-5446
US

IV. Provider business mailing address

1212 E ALGONQUIN RD
ALGONQUIN IL
60102-5446
US

V. Phone/Fax

Practice location:
  • Phone: 224-713-0003
  • Fax: 224-678-7122
Mailing address:
  • Phone: 224-713-0003
  • Fax: 224-678-7122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARIA KORDAS
Title or Position: DIRECTOR
Credential: APN
Phone: 224-713-0003