Healthcare Provider Details

I. General information

NPI: 1740359876
Provider Name (Legal Business Name): MOKENA FAMILY PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11243 W LA PORTE RD
MOKENA IL
60448-1374
US

IV. Provider business mailing address

11243 W LA PORTE RD
MOKENA IL
60448-1374
US

V. Phone/Fax

Practice location:
  • Phone: 708-479-4681
  • Fax: 708-479-8516
Mailing address:
  • Phone: 708-479-4681
  • Fax: 708-479-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number036085722
License Number StateIL

VIII. Authorized Official

Name: RHONDA A DAVIS
Title or Position: MANAGER
Credential:
Phone: 708-479-4681