Healthcare Provider Details

I. General information

NPI: 1558722835
Provider Name (Legal Business Name): TODD LANGELLIER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MAPLE RD
JOLIET IL
60432-1439
US

IV. Provider business mailing address

PO BOX 1123
JACKSON MI
49204-1123
US

V. Phone/Fax

Practice location:
  • Phone: 815-740-1100
  • Fax:
Mailing address:
  • Phone: 800-516-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209014053
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: