=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346953775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MC RISK ASSESSMENT CONSULTING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2022
-----------------------------------------------------
Last Update Date | 12/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1724 W MOTEL RD
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-606-3707
-----------------------------------------------------
Fax | 331-472-1272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 E. STATE STREET BOX #762
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-1467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-284-0510
-----------------------------------------------------
Fax | 331-472-1272
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. SUSAN K MUELLER
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 630-606-3907
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------