=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275826455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE BREAKERS AT EDGEWATER BEACH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2011
-----------------------------------------------------
Last Update Date | 05/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5333 N SHERIDAN RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-7371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-878-5333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5333 N SHERIDAN RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-7371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-878-5333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF SALES AND MARKETING
-----------------------------------------------------
Name | CHERIE DUPOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-878-6136
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251F00000X
-----------------------------------------------------
Taxonomy Name | Home Infusion Agency
-----------------------------------------------------
License Number | 36381847
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------