Healthcare Provider Details

I. General information

NPI: 1992747505
Provider Name (Legal Business Name): PROCARE 4268 YANKEE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S MICHIGAN AVE SUITE 619
CHICAGO IL
60603-5902
US

IV. Provider business mailing address

104 S MICHIGAN AVE SUITE 619
CHICAGO IL
60603-5902
US

V. Phone/Fax

Practice location:
  • Phone: 312-252-7204
  • Fax: 312-332-6140
Mailing address:
  • Phone: 312-252-7204
  • Fax: 312-332-6140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number054015141
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054015141
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054015141
License Number StateIL

VIII. Authorized Official

Name: CRISTIANA MAURICIO
Title or Position: MANAGER, PHARMACY ENROLLMENTS
Credential:
Phone: 401-765-1500