=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811343072
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED INTEGRATIVE MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2016
-----------------------------------------------------
Last Update Date | 05/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2333 N HARLEM AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60707-2718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-518-8166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 N SPRUCE DR
-----------------------------------------------------
City | MAHOMET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61853-9277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-518-8166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILLIAM BLANCHARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-518-8166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209012388
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------