=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003639659
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DNA DIAGNOSTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7310 SUNRISE AVE
-----------------------------------------------------
City | DARIEN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60561-4220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-947-4607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7310 SUNRISE AVE
-----------------------------------------------------
City | DARIEN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60561-4220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAMES SCHILTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-947-4607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0208X
-----------------------------------------------------
Taxonomy Name | Mobile Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------