Healthcare Provider Details

I. General information

NPI: 1689857799
Provider Name (Legal Business Name): MARI DOLORES MERLOS VACA INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 06/09/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5341 W CERMAK RD
CICERO IL
60804-2892
US

IV. Provider business mailing address

3919 W 31ST ST 5341 W CERMAK RD
CICERO IL
60804-2817
US

V. Phone/Fax

Practice location:
  • Phone: 708-656-6430
  • Fax: 708-656-6591
Mailing address:
  • Phone: 708-656-6430
  • Fax: 708-656-6591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: