Healthcare Provider Details

I. General information

NPI: 1194630731
Provider Name (Legal Business Name): ODALY MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1752 CAPITAL ST STE 100
ELGIN IL
60124-7896
US

IV. Provider business mailing address

1068 N CAMDEN LN
SOUTH ELGIN IL
60177-2849
US

V. Phone/Fax

Practice location:
  • Phone: 847-695-3680
  • Fax:
Mailing address:
  • Phone: 847-695-3680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: