Healthcare Provider Details

I. General information

NPI: 1558957324
Provider Name (Legal Business Name): REUBEN C HADZIDE REGISTERED NURSE, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20200 GOVERNORS DR STE 204
OLYMPIA FIELDS IL
60461-1056
US

IV. Provider business mailing address

5291 PROVIDENCE DR.
MATTESON IL
60443
US

V. Phone/Fax

Practice location:
  • Phone: 708-991-7126
  • Fax: 312-229-0067
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number041.270574
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: