Healthcare Provider Details

I. General information

NPI: 1659373132
Provider Name (Legal Business Name): K C A S ENT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2005
Last Update Date: 11/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 N TAYLOR ST
MARENGO IL
60152-2457
US

IV. Provider business mailing address

706 N TAYLOR ST
MARENGO IL
60152-2457
US

V. Phone/Fax

Practice location:
  • Phone: 815-568-0243
  • Fax: 815-568-5350
Mailing address:
  • Phone: 815-568-0243
  • Fax: 815-568-5350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209000890
License Number StateIL

VIII. Authorized Official

Name: MRS. KATHLEEN L LUDWIKOWSKI
Title or Position: ADVANCED PRACTICE NURSE PRACTITIONE
Credential: APN
Phone: 815-568-0243