Healthcare Provider Details

I. General information

NPI: 1194271825
Provider Name (Legal Business Name): VERONICA MACK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9738 S MERRION AVE
CHICAGO IL
60617-4846
US

IV. Provider business mailing address

9738 S MERRION
CHICAGO IL
60617
US

V. Phone/Fax

Practice location:
  • Phone: 773-673-3960
  • Fax:
Mailing address:
  • Phone: 773-673-3960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number07921021
License Number StateIL

VIII. Authorized Official

Name: VERONICA MACK
Title or Position: CNA
Credential: #0792-1021
Phone: 773-673-3960