Healthcare Provider Details

I. General information

NPI: 1093121840
Provider Name (Legal Business Name): MISS KELLEY DAGDICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W PARK AVE
ROUND LAKE IL
60073-3225
US

IV. Provider business mailing address

415 W PARK AVE
ROUND LAKE IL
60073-3225
US

V. Phone/Fax

Practice location:
  • Phone: 847-401-4198
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: