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General NPI Number Information
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NPI Number | 1235327941
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Entity Type | Organization
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Legal Business Name | S. DAVID DEMOREST
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Dates
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Enumeration Date | 10/09/2007
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Last Update Date | 10/09/2007
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Provider Practice Location Address
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Address Line | 8383 BELMONT AVENUE
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City | RIVER GROVE
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State | IL
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Zip | 60171
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Country | US
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Telephone | 708-452-1200
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Fax | 708-452-0157
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Provider Business Mailing Address
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Address Line | P. O BOX 1624
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City | MELROSE PARK
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State | IL
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Zip | 60160
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Country | US
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Telephone | 708-452-1200
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Fax | 708-425-0157
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Authorized Official
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Title or Position | ADMINISTRATOR/OWNER
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Name | JOSEPH L GIACCHINO JR.
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Credential | MD
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Telephone | 708-343-2500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State | IL
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