=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447047501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RCH BRAIN & MIND CENTER IL, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2025
-----------------------------------------------------
Last Update Date | 04/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 142 E ONTARIO ST STE 1400
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-971-3318
-----------------------------------------------------
Fax | 817-862-7238
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1307 8TH AVE STE 403
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-449-9561
-----------------------------------------------------
Fax | 817-862-7238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL ANALYST
-----------------------------------------------------
Name | DANIELLE WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 682-449-9561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------