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General NPI Number Information
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NPI Number | 1255594545
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Entity Type | Organization
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Legal Business Name | KISHWAUKEE CORPORATE HEALTH
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Dates
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Enumeration Date | 07/07/2008
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Last Update Date | 07/07/2008
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Provider Practice Location Address
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Address Line | 3251 COMMERCE DR STE B
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City | DEKALB
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State | IL
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Zip | 60115-7908
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Country | US
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Telephone | 815-754-4882
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Fax |
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Provider Business Mailing Address
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Address Line | 3251 COMMERCE DR STE B
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City | DEKALB
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State | IL
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Zip | 60115-7908
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Country | US
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Telephone | 815-754-4882
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | PATRICK G GANNON
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Credential | D.O.
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Telephone | 815-754-4882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1800X
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Taxonomy Name | Corporate Health Clinic/Center
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License Number | 036-077643
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License Number State | IL
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