Healthcare Provider Details

I. General information

NPI: 1013520113
Provider Name (Legal Business Name): PMR ILLINOIS HOLDING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E SIBLEY BLVD
DOLTON IL
60419-2599
US

IV. Provider business mailing address

1395 NW 167TH ST
MIAMI GARDENS FL
33169-5710
US

V. Phone/Fax

Practice location:
  • Phone: 708-340-7400
  • Fax:
Mailing address:
  • Phone: 305-628-6117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: MARY CHEN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 305-831-4722