Healthcare Provider Details

I. General information

NPI: 1235461278
Provider Name (Legal Business Name): CLINICA SU RED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 COLLINS ST
JOLIET IL
60432-1615
US

IV. Provider business mailing address

5241 S CICERO AVE
CHICAGO IL
60632-4967
US

V. Phone/Fax

Practice location:
  • Phone: 815-726-2288
  • Fax: 815-726-2814
Mailing address:
  • Phone: 708-364-8441
  • Fax: 708-364-8443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: MR. BRENT J RHODE
Title or Position: CHIEF OPERATING OFFICER
Credential: M.S.
Phone: 708-337-7704