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General NPI Number Information
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NPI Number | 1215652011
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Entity Type | Organization
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Legal Business Name | THE PLAINS CLINIC
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Dates
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Enumeration Date | 10/05/2022
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Last Update Date | 01/12/2023
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Provider Practice Location Address
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Address Line | 1541 E FABYAN PKWY STE 101
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City | GENEVA
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State | IL
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Zip | 60134-4105
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Country | US
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Telephone | 630-845-9644
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Fax | 630-845-9678
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Provider Business Mailing Address
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Address Line | 1541 E FABYAN PKWY
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City | GENEVA
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State | IL
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Zip | 60134-4105
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Country | US
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Telephone | 630-845-9644
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Fax | 630-845-9678
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Authorized Official
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Title or Position | PRESIDENT
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Name | ANGEL HEREDIA MD
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Credential | MD
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Telephone | 630-845-9644
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number |
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License Number State |
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