Healthcare Provider Details

I. General information

NPI: 1801617923
Provider Name (Legal Business Name): KIM MACCHIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 OAKBROOK CENTER MALL STE 216
OAK BROOK IL
60523-4713
US

IV. Provider business mailing address

145 E QUINCY ST
RIVERSIDE IL
60546-2175
US

V. Phone/Fax

Practice location:
  • Phone: 630-571-5470
  • Fax:
Mailing address:
  • Phone: 708-785-5515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number220.000051
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: