Healthcare Provider Details

I. General information

NPI: 1467263426
Provider Name (Legal Business Name): CHITTICK SCC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N DUNLAP AVE
SAVOY IL
61874-8403
US

IV. Provider business mailing address

1104 N VERMILION ST
DANVILLE IL
61832-3094
US

V. Phone/Fax

Practice location:
  • Phone: 217-398-2020
  • Fax:
Mailing address:
  • Phone: 217-398-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAWN MALLADY
Title or Position: FACILITY DIRECTOR
Credential:
Phone: 217-398-2020