Healthcare Provider Details

I. General information

NPI: 1316340821
Provider Name (Legal Business Name): MR. BENITO ORDONEZ JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 09/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5966 N MANTON AVE
CHICAGO IL
60646-5553
US

IV. Provider business mailing address

5966 N MANTON AVE
CHICAGO IL
60646-5553
US

V. Phone/Fax

Practice location:
  • Phone: 177-382-2708
  • Fax: 188-831-6099
Mailing address:
  • Phone: 177-382-2708
  • Fax: 188-831-6099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberO63506080017
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: