=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003085812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PMUC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2008
-----------------------------------------------------
Last Update Date | 02/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19164 88TH AVE
-----------------------------------------------------
City | MOKENA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60448-8135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-567-4796
-----------------------------------------------------
Fax | 708-326-2965
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19164 88TH AVE
-----------------------------------------------------
City | MOKENA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60448-8135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-567-4796
-----------------------------------------------------
Fax | 708-326-2965
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | MRS. REBECCA CRAINSMITH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 708-567-4796
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------