Healthcare Provider Details

I. General information

NPI: 1336580026
Provider Name (Legal Business Name): PRESENCE AMBULATORY SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 SHERIDAN RD SUITE 1A
WILMETTE IL
60091-1824
US

IV. Provider business mailing address

1000 REMINGTON BLVD SUITE 100
BOLINGBROOK IL
60440-5114
US

V. Phone/Fax

Practice location:
  • Phone: 847-256-2890
  • Fax: 847-256-2802
Mailing address:
  • Phone: 630-914-2417
  • Fax: 630-914-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELVONNE JONES
Title or Position: MGR, CREDENTIALING
Credential:
Phone: 630-914-2417