Healthcare Provider Details

I. General information

NPI: 1922796689
Provider Name (Legal Business Name): NICHOLAS GARCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 08/14/2023
Certification Date: 08/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7435 W TALCOTT AVE
CHICAGO IL
60631-3707
US

IV. Provider business mailing address

6158 S MASSASOIT AVE
CHICAGO IL
60638-4530
US

V. Phone/Fax

Practice location:
  • Phone: 773-792-5155
  • Fax:
Mailing address:
  • Phone: 224-659-4997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1922796689
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: