Healthcare Provider Details

I. General information

NPI: 1992820757
Provider Name (Legal Business Name): MAYWOOD MELROSE BROADVIEW 89
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 S 8TH AVE
MAYWOOD IL
60153-1903
US

IV. Provider business mailing address

1133 S 8TH AVE
MAYWOOD IL
60153-1903
US

V. Phone/Fax

Practice location:
  • Phone: 708-450-2157
  • Fax: 708-450-1116
Mailing address:
  • Phone: 708-450-2157
  • Fax: 708-450-1116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA BROUGHTON
Title or Position: SUPERINTENDENT
Credential:
Phone: 708-450-2157