Healthcare Provider Details

I. General information

NPI: 1285355040
Provider Name (Legal Business Name): PATRICK JOSEPH FALLON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 MANCHESTER RD STE 1510
WHEATON IL
60187-4561
US

IV. Provider business mailing address

202 S WILLISTON ST
WHEATON IL
60187-5914
US

V. Phone/Fax

Practice location:
  • Phone: 630-653-1717
  • Fax: 630-653-7926
Mailing address:
  • Phone: 630-903-9535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.014822
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: