Healthcare Provider Details

I. General information

NPI: 1164687869
Provider Name (Legal Business Name): CHARM DEVELOPMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 W 14TH ST UNIT C
CHICAGO HEIGHTS IL
60411-2456
US

IV. Provider business mailing address

515 W 14TH ST UNIT C
CHICAGO HEIGHTS IL
60411-2456
US

V. Phone/Fax

Practice location:
  • Phone: 708-503-1105
  • Fax:
Mailing address:
  • Phone: 708-503-1105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036035802
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number335-027231
License Number StateIL

VIII. Authorized Official

Name: BRYAN DAY
Title or Position: CEO
Credential:
Phone: 708-503-1105