Healthcare Provider Details

I. General information

NPI: 1003207051
Provider Name (Legal Business Name): ASHWIN YEGNESWAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 10/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 OCONOR AVE
LA SALLE IL
61301-1216
US

IV. Provider business mailing address

1015 OCONOR AVE
LA SALLE IL
61301-1216
US

V. Phone/Fax

Practice location:
  • Phone: 815-223-0303
  • Fax:
Mailing address:
  • Phone: 815-223-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number056010739
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: