=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093131518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH CARE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2014
-----------------------------------------------------
Last Update Date | 03/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 OGDEN AVE
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-777-8282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1S125 INGERSOLL LN
-----------------------------------------------------
City | VILLA PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60181-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | HANA MALIK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-988-0428
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 041.331241
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 209.006425
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------