Healthcare Provider Details

I. General information

NPI: 1922373497
Provider Name (Legal Business Name): PRIMECARE DIAGNOSTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W ESTES AVE
CHICAGO IL
60645-2903
US

IV. Provider business mailing address

2801 W ESTES AVE
CHICAGO IL
60645-2903
US

V. Phone/Fax

Practice location:
  • Phone: 708-452-6842
  • Fax:
Mailing address:
  • Phone: 708-452-6842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. CHANDARANA KANTI
Title or Position: MD
Credential: MD
Phone: 708-452-6842