Healthcare Provider Details

I. General information

NPI: 1659821221
Provider Name (Legal Business Name): TCA HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 E. 130TH ST
CHICAGO IL
60628
US

IV. Provider business mailing address

1029 E 130TH ST
CHICAGO IL
60628-6908
US

V. Phone/Fax

Practice location:
  • Phone: 773-995-1462
  • Fax: 773-995-7985
Mailing address:
  • Phone: 773-995-1462
  • Fax: 773-995-7985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1578936696
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number1588701452
License Number StateIL

VIII. Authorized Official

Name: MS. MARQUETTA D HALL
Title or Position: BILLING SPECIALIST
Credential: MD
Phone: 708-856-7556