=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275941577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ONSITE HEALTH PARTNERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2014
-----------------------------------------------------
Last Update Date | 07/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2553 S MILLARD AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60623-3943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-788-8991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2553 S MILLARD AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60623-3943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-788-8991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PART OWNER
-----------------------------------------------------
Name | MR. ALPHONSE GONZALES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-788-8991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------