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General NPI Number Information
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NPI Number | 1992820757
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Entity Type | Organization
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Legal Business Name | MAYWOOD MELROSE BROADVIEW 89
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1133 S 8TH AVE
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City | MAYWOOD
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State | IL
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Zip | 60153-1903
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Country | US
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Telephone | 708-450-2157
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Fax | 708-450-1116
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Provider Business Mailing Address
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Address Line | 1133 S 8TH AVE
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City | MAYWOOD
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State | IL
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Zip | 60153-1903
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Country | US
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Telephone | 708-450-2157
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Fax | 708-450-1116
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Authorized Official
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Title or Position | SUPERINTENDENT
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Name | CYNTHIA BROUGHTON
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Credential |
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Telephone | 708-450-2157
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS1000X
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Taxonomy Name | Student Health Clinic/Center
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License Number |
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License Number State |
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