Healthcare Provider Details

I. General information

NPI: 1245061506
Provider Name (Legal Business Name): LIMARIZ REBOLLEDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 W BELMONT AVE
CHICAGO IL
60634-4384
US

IV. Provider business mailing address

507 N 17TH ST
MILWAUKEE WI
53233-2104
US

V. Phone/Fax

Practice location:
  • Phone: 773-736-1830
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.010814
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: