Healthcare Provider Details

I. General information

NPI: 1568240315
Provider Name (Legal Business Name): MPAC SMH OF CALIFORNIA ACO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N HALSTED ST STE 803
CHICAGO IL
60657-6185
US

IV. Provider business mailing address

PO BOX 80693
CITY OF INDUSTRY CA
91716-8415
US

V. Phone/Fax

Practice location:
  • Phone: 888-705-8722
  • Fax: 888-705-8722
Mailing address:
  • Phone: 888-705-8722
  • Fax: 888-705-8722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: SEAN CANNONE
Title or Position: OWNER / CMO
Credential: DO
Phone: 888-660-4425