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General NPI Number Information
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NPI Number | 1164768354
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Entity Type | Organization
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Legal Business Name | JENCARE NEIGHBORHOOD MEDICAL CENTER SOUTH CHICAGO, LLC
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Dates
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Enumeration Date | 12/17/2012
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Last Update Date | 10/31/2024
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Provider Practice Location Address
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Address Line | 2231 E 95TH ST
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City | CHICAGO
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State | IL
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Zip | 60617-4804
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Country | US
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Telephone | 305-628-6117
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Fax | 312-276-9660
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Provider Business Mailing Address
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Address Line | 1395 NW 167TH ST
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City | MIAMI
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State | FL
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Zip | 33169-5710
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Country | US
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Telephone | 305-628-6117
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | MARY CHEN
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Credential |
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Telephone | 305-831-4722
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | 036.131322
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 036.131322
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License Number State | IL
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