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General NPI Number Information
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NPI Number | 1528489739
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Entity Type | Organization
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Legal Business Name | MY FAMILY DOC LLC
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Dates
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Enumeration Date | 12/16/2013
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Last Update Date | 11/03/2023
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Provider Practice Location Address
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Address Line | 2001-03 ESSINGTON RD
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City | JOLIET
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State | IL
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Zip | 60435
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Country | US
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Telephone | 815-733-6888
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Fax | 815-733-6890
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Provider Business Mailing Address
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Address Line | 2001-03 ESSINGTON RD
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City | JOLIET
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State | IL
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Zip | 60435
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Country | US
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Telephone | 815-733-6888
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Fax | 815-733-6890
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Authorized Official
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Title or Position | OWNER, PHYSICIAN
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Name | MOLLY D'COSTA
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Credential | DO
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Telephone | 815-733-6888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036116813
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License Number State | IL
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