Healthcare Provider Details

I. General information

NPI: 1316439722
Provider Name (Legal Business Name): OUR MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 07/08/2021
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 DUNHAM RD STE 300
SAINT CHARLES IL
60174-1431
US

IV. Provider business mailing address

451 DUNHAM RD STE 300
SAINT CHARLES IL
60174-1431
US

V. Phone/Fax

Practice location:
  • Phone: 630-521-3110
  • Fax: 630-296-8965
Mailing address:
  • Phone: 630-521-3110
  • Fax: 630-296-8965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209013778
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209013778
License Number StateIL

VIII. Authorized Official

Name: CECILIA BERUMEN
Title or Position: NURSE PRACTITIONER / PSYCH
Credential: APRN FPA
Phone: 630-521-3110