Healthcare Provider Details

I. General information

NPI: 1780178780
Provider Name (Legal Business Name): ANDRE BEANS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 E 21ST ST
CHICAGO IL
60616-1730
US

IV. Provider business mailing address

4626 S EVANS AVE
CHICAGO IL
60653-4244
US

V. Phone/Fax

Practice location:
  • Phone: 312-934-3360
  • Fax:
Mailing address:
  • Phone: 312-934-3360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: