Healthcare Provider Details

I. General information

NPI: 1881669547
Provider Name (Legal Business Name): RENAE LYNN ST.CLAIR ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8311 N ROUTE 31
RICHMOND IL
60071
US

IV. Provider business mailing address

PO BOX 862 742 KRESSWOOD DR.
MCHENRY IL
60051-9014
US

V. Phone/Fax

Practice location:
  • Phone: 815-678-7561
  • Fax:
Mailing address:
  • Phone: 815-403-6614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: