=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548280142
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WENTZEL SHORE CAPITAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10436 RT 47 SUITE 105
-----------------------------------------------------
City | HUNTLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-515-3366
-----------------------------------------------------
Fax | 847-515-3356
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10436 RT 47 SUITE 105
-----------------------------------------------------
City | HUNTLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-515-3366
-----------------------------------------------------
Fax | 847-515-3356
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | MRS. AMY D ZORNOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-658-1117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------