Healthcare Provider Details

I. General information

NPI: 1760858633
Provider Name (Legal Business Name): CLINIC 1, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4759 N KEDZIE AVE SUITE 100
CHICAGO IL
60625-4420
US

IV. Provider business mailing address

5901 N CICERO AVE SUITE 400
CHICAGO IL
60646-5717
US

V. Phone/Fax

Practice location:
  • Phone: 773-685-9900
  • Fax: 773-685-9910
Mailing address:
  • Phone: 773-685-9900
  • Fax: 773-685-9910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. KASHIF M RIAZ
Title or Position: CEO
Credential:
Phone: 773-996-0919