Healthcare Provider Details

I. General information

NPI: 1740673599
Provider Name (Legal Business Name): AMCCAIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2015
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 E 53RD ST #932
CHICAGO IL
60615-4573
US

IV. Provider business mailing address

1507 E 53RD ST #932
CHICAGO IL
60615-4573
US

V. Phone/Fax

Practice location:
  • Phone: 219-805-4947
  • Fax:
Mailing address:
  • Phone: 219-805-4947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number146006026
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number146006026
License Number StateIL

VIII. Authorized Official

Name: AKILIA MCCAIN
Title or Position: PRESIDENT
Credential: M.S.
Phone: 219-805-4947