Healthcare Provider Details

I. General information

NPI: 1679008734
Provider Name (Legal Business Name): DR MEDA PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 N HUMPHREY AVE
OAK PARK IL
60302-1111
US

IV. Provider business mailing address

1215 N HUMPHREY AVE
OAK PARK IL
60302-1111
US

V. Phone/Fax

Practice location:
  • Phone: 708-378-8079
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number036119419
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: IZUCHUKWU NWAFO
Title or Position: CEO
Credential:
Phone: 708-378-8079