Healthcare Provider Details

I. General information

NPI: 1932674314
Provider Name (Legal Business Name): CARLOS A QUEVEDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 N ARLINGTON HEIGHTS RD
ARLINGTON HEIGHTS IL
60004-4767
US

IV. Provider business mailing address

600 W FULTON ST STE 200
CHICAGO IL
60661-1262
US

V. Phone/Fax

Practice location:
  • Phone: 847-342-1554
  • Fax: 847-342-1711
Mailing address:
  • Phone: 312-526-2411
  • Fax: 312-526-2329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number041389632
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: