Healthcare Provider Details

I. General information

NPI: 1013458827
Provider Name (Legal Business Name): DEBORAH PARRA PEDORTHIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 RIDGE RD
LANSING IL
60438-3379
US

IV. Provider business mailing address

727 S SALEM DR
SCHAUMBURG IL
60193-2764
US

V. Phone/Fax

Practice location:
  • Phone: 708-418-0000
  • Fax: 708-418-0009
Mailing address:
  • Phone: 708-418-0008
  • Fax: 708-418-0009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number212.000178
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: