Healthcare Provider Details

I. General information

NPI: 1497762009
Provider Name (Legal Business Name): FIRST ASST OF NORTHERN IL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6785 WEAVER RD STE D
ROCKFORD IL
61114-8055
US

IV. Provider business mailing address

6785 WEAVER RD STE D
ROCKFORD IL
61114-8055
US

V. Phone/Fax

Practice location:
  • Phone: 920-451-8142
  • Fax:
Mailing address:
  • Phone: 920-451-8142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number
License Number State

VIII. Authorized Official

Name: GERARDO SANCHEZ
Title or Position: PRESIDENT
Credential: RN
Phone: 920-451-8142