Healthcare Provider Details

I. General information

NPI: 1225206352
Provider Name (Legal Business Name): CICERO DISTRICT 99
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5110 W 24TH ST
CICERO IL
60804-2948
US

IV. Provider business mailing address

5110 W 24TH ST
CICERO IL
60804-2948
US

V. Phone/Fax

Practice location:
  • Phone: 708-863-4856
  • Fax:
Mailing address:
  • Phone: 708-863-4856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: MARGE CIESLWIWICCZ
Title or Position: DIRECTOR
Credential:
Phone: 708-863-4856