Healthcare Provider Details

I. General information

NPI: 1407920473
Provider Name (Legal Business Name): WINDHAM MEDICAL SUPPLIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2056 EAST 71ST STREET
CHICAGO IL
60649-2117
US

IV. Provider business mailing address

2056 EAST 71ST STREET
CHICAGO IL
60649-2117
US

V. Phone/Fax

Practice location:
  • Phone: 773-288-2844
  • Fax: 773-288-2848
Mailing address:
  • Phone: 773-288-2844
  • Fax: 773-288-2848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. MATT WINDHAM JR.
Title or Position: OWNER
Credential:
Phone: 773-288-2844