Healthcare Provider Details

I. General information

NPI: 1356485809
Provider Name (Legal Business Name): MINUTECLINIC DIAGNOSTIC OF ILLINOIS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 W LINCOLN HWY
MOKENA IL
60448-8208
US

IV. Provider business mailing address

1 CVS DR MINUTECLINIC MC-2295
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax: 401-406-3539
Mailing address:
  • Phone: 401-770-3813
  • Fax: 401-406-3539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH JEAN PINCINCE
Title or Position: ADMINISTRATOR
Credential:
Phone: 401-770-3813