=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518314608
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TELECAB ILLINOIS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2016
-----------------------------------------------------
Last Update Date | 05/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 N CHICAGO ST
-----------------------------------------------------
City | JOLIET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60432-1747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-726-8294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 CLEARWATER DR
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-1927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ANTHONY BENISH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-560-9840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 344600000X
-----------------------------------------------------
Taxonomy Name | Taxi
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------