=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942460381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVAK FAMILY MEDICAL CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2008
-----------------------------------------------------
Last Update Date | 03/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 E NORTH AVE SUITE 5
-----------------------------------------------------
City | VILLA PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60181-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-834-0132
-----------------------------------------------------
Fax | 630-834-0319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 E NORTH AVE SUITE 5
-----------------------------------------------------
City | VILLA PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60181-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-834-0132
-----------------------------------------------------
Fax | 630-834-0319
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. TERESA NOVAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-834-0132
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------