Healthcare Provider Details

I. General information

NPI: 1104722305
Provider Name (Legal Business Name): MARIE GRACE JIMENEZ DANGALAN CPED, CFO, CTO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2026
Last Update Date: 10/15/2026
Certification Date: 10/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

820 S. DAMEN AVENUE OGDEN BUILDING 3RD FLOOR
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 224-713-6485
  • Fax:
Mailing address:
  • Phone: 224-713-6485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberCFO04547
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberCPED4548
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: