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General NPI Number Information
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NPI Number | 1962115857
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Entity Type | Organization
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Legal Business Name | MAC LIMOUSINE SERVICE INC
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Dates
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Enumeration Date | 01/05/2023
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Last Update Date | 01/19/2023
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Provider Practice Location Address
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Address Line | 347 S CICERO AVE
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City | CHICAGO
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State | IL
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Zip | 60644-4905
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Country | US
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Telephone | 773-746-1399
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Fax | 773-626-2118
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Provider Business Mailing Address
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Address Line | 347 S CICERO AVE
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City | CHICAGO
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State | IL
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Zip | 60644-4905
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Country | US
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Telephone | 773-746-1399
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Fax | 773-626-2118
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Authorized Official
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Title or Position | CEO
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Name | DERRICK DAMON MCCOLLUM
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Credential |
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Telephone | 773-746-1399
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251T00000X
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Taxonomy Name | PACE Provider Organization
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License Number |
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License Number State |
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