=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982356325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWIFT DIAGNOSTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2022
-----------------------------------------------------
Last Update Date | 01/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4320 W AUGUSTA BLVD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60651-3430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-410-3285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4320 W AUGUSTA BLVD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60651-3430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-410-3285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. TROY STAMPS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-410-3285
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------