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General NPI Number Information
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NPI Number | 1801960208
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Entity Type | Organization
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Legal Business Name | MAVENA CHICAGO CLINIC, INC.
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1455 E GOLF RD STE 120
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City | DES PLAINES
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State | IL
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Zip | 60016-1253
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Country | US
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Telephone | 847-298-9400
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Fax | 847-298-7660
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Provider Business Mailing Address
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Address Line | 500 N MICHIGAN AVE STE 300
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City | CHICAGO
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State | IL
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Zip | 60611-3775
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Country | US
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Telephone | 847-298-9400
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Fax | 847-298-7660
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | JERRI MCGINNIS
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Credential |
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Telephone | 847-298-9400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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