=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639792062
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ICAREUCAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2020
-----------------------------------------------------
Last Update Date | 05/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7634 W LAKEVIEW TER
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-8653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-351-2445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7634 W LAKEVIEW TER
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-8653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-351-2445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | MRS. LORELLE POP
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 815-351-2445
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------