Healthcare Provider Details

I. General information

NPI: 1740304757
Provider Name (Legal Business Name): FULLERTON OCCUPATIONAL MEDICINE & IMMEDIATE CARE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 W FULLERTON AVE
CHICAGO IL
60647-2415
US

IV. Provider business mailing address

3409 W FULLERTON AVE
CHICAGO IL
60647-2415
US

V. Phone/Fax

Practice location:
  • Phone: 773-486-5001
  • Fax:
Mailing address:
  • Phone: 773-486-5001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number364061160
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number364061160
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number364061160
License Number StateIL

VIII. Authorized Official

Name: RENLIN XIA
Title or Position: PRESIDENT
Credential: MD
Phone: 773-486-5001