Healthcare Provider Details

I. General information

NPI: 1992407712
Provider Name (Legal Business Name): MR. COTOREY JAMES SEALS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: COTOREY JAMES SEALS

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3511 W FILLMORE ST
CHICAGO IL
60624-4312
US

IV. Provider business mailing address

1147 W OHIO ST STE 103
CHICAGO IL
60642-5874
US

V. Phone/Fax

Practice location:
  • Phone: 239-810-2872
  • Fax:
Mailing address:
  • Phone: 312-772-9796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.018822
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: