Healthcare Provider Details

I. General information

NPI: 1528136728
Provider Name (Legal Business Name): CENTRAD HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 N FENWAY ST
CASPER WY
82601-2134
US

IV. Provider business mailing address

184 SHUMAN BLVD SUITE 130
NAPERVILLE IL
60563-1219
US

V. Phone/Fax

Practice location:
  • Phone: 307-266-4434
  • Fax: 307-266-4454
Mailing address:
  • Phone: 630-369-5840
  • Fax: 630-369-5436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number203000502
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number2389
License Number StateWY

VIII. Authorized Official

Name: GIDGETT ANN CALLAGHAN
Title or Position: VP, REIMBURSEMENT
Credential:
Phone: 630-369-5840