Healthcare Provider Details

I. General information

NPI: 1134498645
Provider Name (Legal Business Name): DOUGLAS VINCENT CARTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 N RAYNOR AVE
JOLIET IL
60435-6025
US

IV. Provider business mailing address

503 N RAYNOR AVE
JOLIET IL
60435-6025
US

V. Phone/Fax

Practice location:
  • Phone: 815-740-1987
  • Fax: 815-740-1994
Mailing address:
  • Phone: 815-740-1987
  • Fax: 815-740-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number238000300
License Number StateIL

VIII. Authorized Official

Name: MR. DOUGLAS V CARTER
Title or Position: OWNER
Credential: RN, RSA, CSA
Phone: 815-740-1987