Healthcare Provider Details

I. General information

NPI: 1639482235
Provider Name (Legal Business Name): YOUR MEDICOS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 BUSCH PKWY
BUFFALO GROVE IL
60089-4505
US

IV. Provider business mailing address

1300 BUSCH PKWY
BUFFALO GROVE IL
60089-4505
US

V. Phone/Fax

Practice location:
  • Phone: 847-850-5882
  • Fax: 847-850-5892
Mailing address:
  • Phone: 847-850-5882
  • Fax: 847-850-5892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038010683
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number036074991
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number036074991
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number036074991
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number036074991
License Number StateIL

VIII. Authorized Official

Name: MRS. NIKITA TAVKAR
Title or Position: MANAGER
Credential:
Phone: 847-850-5882