=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184100984
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD JOSEPH HANSEN AMCA-4709
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2018
-----------------------------------------------------
Last Update Date | 01/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 541 SPRUCE RD
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-880-9543
-----------------------------------------------------
Fax | 630-596-1404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 541 SPRUCE RD
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-880-9543
-----------------------------------------------------
Fax | 630-596-1404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246RP1900X
-----------------------------------------------------
Taxonomy Name | Phlebotomy Technician
-----------------------------------------------------
License Number | AMCA-4709
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 247ZC0005X
-----------------------------------------------------
Taxonomy Name | Clinical Laboratory Director (Non-physician)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------