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General NPI Number Information
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NPI Number | 1568262525
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Entity Type | Individual
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Provider Name | CHARLES KINNEY JR.
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Gender | Male
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Dates
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Enumeration Date | 03/18/2025
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Last Update Date | 03/18/2025
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Provider Practice Location Address
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Address Line | 112 W PARK ST APT 1E
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City | ELWOOD
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State | IL
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Zip | 60421-9628
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Country | US
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Telephone | 815-540-2875
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Fax |
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Provider Business Mailing Address
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Address Line | 3 DAVISON ST APT 2
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City | JOLIET
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State | IL
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Zip | 60433-1369
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Country | US
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Telephone | 815-540-2875
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 372500000X
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Taxonomy Name | Chore Provider
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License Number |
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License Number State | IL
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