Healthcare Provider Details

I. General information

NPI: 1134033731
Provider Name (Legal Business Name): CPV SOUTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4659 S COTTAGE GROVE AVE
CHICAGO IL
60653-4757
US

IV. Provider business mailing address

39 ARKANSAS ST
SAN FRANCISCO CA
94107-2434
US

V. Phone/Fax

Practice location:
  • Phone: 844-664-2248
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number StateNULL

VIII. Authorized Official

Name: MATTHEW BENNETT
Title or Position: CEO
Credential:
Phone: 844-664-2248