Healthcare Provider Details

I. General information

NPI: 1063923316
Provider Name (Legal Business Name): LUIS R FLORES I RN,CDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 W DIVISION ST
CHICAGO IL
60622-8151
US

IV. Provider business mailing address

272 ADDISON RD
RIVERSIDE IL
60546-2039
US

V. Phone/Fax

Practice location:
  • Phone: 312-770-2235
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number041290690
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: