Healthcare Provider Details

I. General information

NPI: 1013638832
Provider Name (Legal Business Name): MED-ADVO-C LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 08/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 YORKSHIRE CT
JOLIET IL
60431-8088
US

IV. Provider business mailing address

1505 YORKSHIRE CT
JOLIET IL
60431-8088
US

V. Phone/Fax

Practice location:
  • Phone: 708-972-9715
  • Fax: 630-326-3382
Mailing address:
  • Phone: 708-972-0915
  • Fax: 630-326-3382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: APRIL MCMURRAY-WHITE
Title or Position: CEO/OWNER
Credential:
Phone: 708-972-9715