Healthcare Provider Details

I. General information

NPI: 1700927092
Provider Name (Legal Business Name): BEACON THERAPEUTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1912 W 103RD ST
CHICAGO IL
60643-2625
US

IV. Provider business mailing address

1912 W 103RD ST
CHICAGO IL
60643-2625
US

V. Phone/Fax

Practice location:
  • Phone: 773-298-1243
  • Fax: 773-298-1078
Mailing address:
  • Phone: 773-298-1243
  • Fax: 773-298-1078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL WASHINGTON
Title or Position: CFO
Credential:
Phone: 773-298-1243