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General NPI Number Information
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NPI Number | 1013574532
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Entity Type | Organization
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Legal Business Name | GREEN HEALTHCARE CLINIC LLC
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Dates
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Enumeration Date | 05/20/2019
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Last Update Date | 05/20/2019
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Provider Practice Location Address
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Address Line | 4425 W 63RD ST STE 204
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City | CHICAGO
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State | IL
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Zip | 60629-5565
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Country | US
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Telephone | 888-876-7012
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Fax |
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Provider Business Mailing Address
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Address Line | 825 WOODLEA RD
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City | KANKAKEE
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State | IL
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Zip | 60901-8199
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Country | US
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Telephone | 815-937-0552
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. JACINTA GREEN
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Credential | MD
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Telephone | 815-937-0552
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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