Healthcare Provider Details

I. General information

NPI: 1770599946
Provider Name (Legal Business Name): DOUGLAS VINCENT CARTER RN, RSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 01/17/2010
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 Number238.000004
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: