Healthcare Provider Details

I. General information

NPI: 1780944264
Provider Name (Legal Business Name): MVC - NILES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 05/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7177 N MILWAUKEE AVE
NILES IL
60714-4424
US

IV. Provider business mailing address

2001 BUTTERFIELD RD SUITE 100
DOWNERS GROVE IL
60515-1050
US

V. Phone/Fax

Practice location:
  • Phone: 630-322-9126
  • Fax: 630-322-9128
Mailing address:
  • Phone: 630-322-9126
  • Fax: 630-322-9128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number042619879
License Number StateIL

VIII. Authorized Official

Name: DR. JAMES GORDON WRIGHT
Title or Position: CEO PRESEDENT
Credential: M.D.
Phone: 630-322-9126