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General NPI Number Information
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NPI Number | 1104111848
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Entity Type | Organization
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Legal Business Name | MENS HEALTH CHICAGO LLC
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Dates
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Enumeration Date | 06/10/2011
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Last Update Date | 06/10/2011
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Provider Practice Location Address
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Address Line | 1396 NEWCASTLE CT
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City | BARTLETT
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State | IL
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Zip | 60103-2989
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Country | US
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Telephone | 480-229-2013
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Fax |
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Provider Business Mailing Address
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Address Line | 12878 N 119TH ST
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City | SCOTTSDALE
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State | AZ
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Zip | 85259-2736
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | JR WADE
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Credential |
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Telephone | 480-229-1986
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | AP3397
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License Number State | AZ
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