Healthcare Provider Details

I. General information

NPI: 1386181675
Provider Name (Legal Business Name): M.D DEVELOPMENTAL AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3335 S INDIANA AVE
CHICAGO IL
60616-3838
US

IV. Provider business mailing address

1501 E 72ND ST
CHICAGO IL
60619-1511
US

V. Phone/Fax

Practice location:
  • Phone: 708-253-9271
  • Fax:
Mailing address:
  • Phone: 773-407-7558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: DEBRA STEWART
Title or Position: OWNER
Credential:
Phone: 773-407-7558