Healthcare Provider Details

I. General information

NPI: 1073293122
Provider Name (Legal Business Name): ALEXANDER ESTRADA I B.A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11560 S KEDZIE AVE
MERRIONETTE PARK IL
60803-4517
US

IV. Provider business mailing address

11560 S KEDZIE AVE STE 200
MERRIONETTE PARK IL
60803-4517
US

V. Phone/Fax

Practice location:
  • Phone: 872-315-6494
  • Fax:
Mailing address:
  • Phone: 708-974-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: