Healthcare Provider Details

I. General information

NPI: 1982723623
Provider Name (Legal Business Name): CFAC INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S JOHN ST
DWIGHT IL
60420-1413
US

IV. Provider business mailing address

9 MACKENZIE CT
BLOOMINGTON IL
61704-7047
US

V. Phone/Fax

Practice location:
  • Phone: 815-584-9000
  • Fax:
Mailing address:
  • Phone: 309-212-3066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016004981
License Number StateIL

VIII. Authorized Official

Name: WILBERT MARC LEONARD
Title or Position: OWNER
Credential: DPM
Phone: 309-212-3066