Healthcare Provider Details

I. General information

NPI: 1497574883
Provider Name (Legal Business Name): MR. CARLETON BRUCE SYPH II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 S WESTERN AVE
CHICAGO IL
60636-1527
US

IV. Provider business mailing address

848 DODGE AVE # 426
EVANSTON IL
60202-1506
US

V. Phone/Fax

Practice location:
  • Phone: 224-725-0765
  • Fax:
Mailing address:
  • Phone: 224-725-0765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: