=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518210327
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VILLAGE DERMATOLOGY, SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2012
-----------------------------------------------------
Last Update Date | 10/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 LINDEN AVE
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-2844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-920-9177
-----------------------------------------------------
Fax | 847-920-9188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 LINDEN AVE
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-2844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-920-9177
-----------------------------------------------------
Fax | 847-920-9188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CECELIA H RICKETTS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 847-920-9177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 042619944
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------