Healthcare Provider Details

I. General information

NPI: 1972784429
Provider Name (Legal Business Name): WEST TOWN MEDICAL ASSOCIATES,SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1859 W CHICAGO AVE
CHICAGO IL
60622-5513
US

IV. Provider business mailing address

3 NORRIS DR
BURR RIDGE IL
60527-5124
US

V. Phone/Fax

Practice location:
  • Phone: 312-829-4636
  • Fax:
Mailing address:
  • Phone: 630-655-0544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. JULIO LARA VALLE
Title or Position: PRESIDENT
Credential: MD
Phone: 312-829-4636