=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346958766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHEL CLINIC & URGENT CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2022
-----------------------------------------------------
Last Update Date | 02/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 E SAUK TRL
-----------------------------------------------------
City | SAUK VILLAGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60411-4955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-506-3188
-----------------------------------------------------
Fax | 815-205-4821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 E SAUK TRL
-----------------------------------------------------
City | SAUK VILLAGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60411-4955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-506-3188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. CHUKS B AKAEZE
-----------------------------------------------------
Credential | RN/BSN
-----------------------------------------------------
Telephone | 708-506-3188
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------