Healthcare Provider Details

I. General information

NPI: 1801298302
Provider Name (Legal Business Name): KIM OPALACZ RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17613 71ST AVE
TINLEY PARK IL
60477-3817
US

IV. Provider business mailing address

PO BOX 309
MONEE IL
60449-0309
US

V. Phone/Fax

Practice location:
  • Phone: 708-532-4338
  • Fax:
Mailing address:
  • Phone: 708-534-2168
  • Fax: 708-534-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number041211014
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: