Healthcare Provider Details

I. General information

NPI: 1619180106
Provider Name (Legal Business Name): SOUTHSIDE ASSISTANTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21200 S LAGRANGE RD SUITE 134
FRANKFORT IL
60423-2003
US

IV. Provider business mailing address

21200 S LAGRANGE RD SUITE 134
FRANKFORT IL
60423-2003
US

V. Phone/Fax

Practice location:
  • Phone: 708-256-0816
  • Fax: 815-534-5576
Mailing address:
  • Phone: 708-256-0816
  • Fax: 815-534-5576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209009090
License Number StateIL

VIII. Authorized Official

Name: BRIAN JOHNSON
Title or Position: FAMILY NURSE PRACTITIONER
Credential: FNP-C, MSN
Phone: 708-256-0816