Healthcare Provider Details

I. General information

NPI: 1306076773
Provider Name (Legal Business Name): CARINA IBARRA A.A.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2717 N SAINT LOUIS AVE
CHICAGO IL
60647-1228
US

IV. Provider business mailing address

2717 N SAINT LOUIS AVE
CHICAGO IL
60647-1228
US

V. Phone/Fax

Practice location:
  • Phone: 773-905-4730
  • Fax: 773-685-3669
Mailing address:
  • Phone: 773-905-4730
  • Fax: 773-685-3669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: