Healthcare Provider Details

I. General information

NPI: 1043686165
Provider Name (Legal Business Name): FELIPE VILLALOBOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2724 N MARMORA AVE
CHICAGO IL
60639-1220
US

IV. Provider business mailing address

2724 N MARMORA AVE
CHICAGO IL
60639-1220
US

V. Phone/Fax

Practice location:
  • Phone: 773-504-6691
  • Fax:
Mailing address:
  • Phone: 773-504-6691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238000320
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: