Healthcare Provider Details

I. General information

NPI: 1710095385
Provider Name (Legal Business Name): ALLERGY AND ASTHMA CLINIC SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 N HAMMES AVE
JOLIET IL
60435-8100
US

IV. Provider business mailing address

229 N HAMMES AVE
JOLIET IL
60435-8100
US

V. Phone/Fax

Practice location:
  • Phone: 815-744-2300
  • Fax:
Mailing address:
  • Phone: 815-744-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: THEODORE M KANELLAKES
Title or Position: DR
Credential: MD
Phone: 815-744-2300