Healthcare Provider Details

I. General information

NPI: 1295822716
Provider Name (Legal Business Name): CICERO MEDICAL CLINICA SAN LAZARO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5712 W 35TH ST
CICERO IL
60804-4222
US

IV. Provider business mailing address

5712 W 35TH ST
CICERO IL
60804-4222
US

V. Phone/Fax

Practice location:
  • Phone: 708-656-5485
  • Fax: 708-656-5657
Mailing address:
  • Phone: 708-656-5485
  • Fax: 708-656-5657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GERARD LICEA
Title or Position: REGISTERED AGENT
Credential: MBA
Phone: 708-656-5485