Healthcare Provider Details

I. General information

NPI: 1780913152
Provider Name (Legal Business Name): ICRF, INC. MEDICAL PLAZA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 ESSINGTON RD
JOLIET IL
60435-4912
US

IV. Provider business mailing address

744 ESSINGTON RD
JOLIET IL
60435-4912
US

V. Phone/Fax

Practice location:
  • Phone: 815-741-4500
  • Fax: 815-741-3600
Mailing address:
  • Phone: 815-741-4500
  • Fax: 815-741-3600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number24906
License Number StateIL

VIII. Authorized Official

Name: MR. JOSHUA URUETA
Title or Position: OFFICE MANAGER
Credential:
Phone: 815-741-4500