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General NPI Number Information
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NPI Number | 1396156717
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Entity Type | Organization
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Legal Business Name | CAMBODIAN ASSOCIATION OF ILLINOIS
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Dates
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Enumeration Date | 05/20/2014
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Last Update Date | 05/19/2016
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Provider Practice Location Address
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Address Line | 123 E LAKE ST STE 204
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1100
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Country | US
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Telephone | 773-878-7090
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Fax | 773-878-5299
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Provider Business Mailing Address
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Address Line | 2831 W LAWRENCE AVE
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City | CHICAGO
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State | IL
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Zip | 60625-3619
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Country | US
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Telephone | 773-878-7090
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | KOMPHA SETH
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Credential |
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Telephone | 773-878-7090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | INH1413006
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | INH1402004
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | INH1012030
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License Number State | IL
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