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General NPI Number Information
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NPI Number | 1669797437
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Entity Type | Organization
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Legal Business Name | BLUE DIAMOND HEALTH CARE LLC
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Dates
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Enumeration Date | 04/05/2010
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Last Update Date | 04/05/2010
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Provider Practice Location Address
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Address Line | 2749 W NORTH AVE
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City | CHICAGO
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State | IL
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Zip | 60647-5246
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Country | US
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Telephone | 773-292-9660
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Fax |
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Provider Business Mailing Address
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Address Line | 2749 W NORTH AVE
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City | CHICAGO
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State | IL
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Zip | 60647-5246
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Country | US
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Telephone | 773-292-9660
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | MR. JAMES JAMES VACRACOS
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Credential | PA-C
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Telephone | 219-765-3431
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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