Healthcare Provider Details

I. General information

NPI: 1295983922
Provider Name (Legal Business Name): MR. LEONARD JAMES SKONIECKE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2008
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3153 183RD ST
HOMEWOOD IL
60430-2806
US

IV. Provider business mailing address

3153 183RD ST
HOMEWOOD IL
60430-2806
US

V. Phone/Fax

Practice location:
  • Phone: 708-799-8411
  • Fax:
Mailing address:
  • Phone: 708-799-8411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-036314
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: