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General NPI Number Information
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NPI Number | 1306161427
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Entity Type | Organization
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Legal Business Name | CENTERCORE MEDICAL LLC
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Dates
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Enumeration Date | 03/31/2010
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Last Update Date | 03/31/2010
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Provider Practice Location Address
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Address Line | 720 S PARK AVE
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City | HERRIN
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State | IL
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Zip | 62948-3816
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Country | US
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Telephone | 618-713-6286
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Fax | 618-985-4636
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Provider Business Mailing Address
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Address Line | 704 GRACE LN
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City | CARTERVILLE
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State | IL
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Zip | 62918-1058
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Country | US
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Telephone | 618-713-6286
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Fax | 618-985-4636
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Authorized Official
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Title or Position | OWNER
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Name | CORENE MAVIGLIANO
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Credential |
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Telephone | 618-713-6286
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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