Healthcare Provider Details

I. General information

NPI: 1457344657
Provider Name (Legal Business Name): OCCU - SPORTS MED CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 HARRISON ST
BELLWOOD IL
60104-2450
US

IV. Provider business mailing address

2615 HARRISON ST
BELLWOOD IL
60104-2450
US

V. Phone/Fax

Practice location:
  • Phone: 708-493-0199
  • Fax: 708-493-9683
Mailing address:
  • Phone: 708-493-0199
  • Fax: 708-493-9683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036078648
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036043379
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036078552
License Number StateIL

VIII. Authorized Official

Name: CASTOLINA SOLIS
Title or Position: BILLING MANAGER
Credential: CPC
Phone: 708-493-0199