Healthcare Provider Details

I. General information

NPI: 1144786419
Provider Name (Legal Business Name): CODY D CARDILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 S GLADSTONE AVE
AURORA IL
60506-4877
US

IV. Provider business mailing address

13356 VICARAGE DR
PLAINFIELD IL
60585-5050
US

V. Phone/Fax

Practice location:
  • Phone: 630-892-6431
  • Fax:
Mailing address:
  • Phone: 815-992-9997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: