Healthcare Provider Details

I. General information

NPI: 1750321303
Provider Name (Legal Business Name): JESSE BROWN VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

17732 EXCHANGE AVE
LANSING IL
60438-4804
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-6399
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number05008375A
License Number StateIN

VIII. Authorized Official

Name: MR. JUSTIN LLAMAS
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 708-889-0599