MEDICARE: KING COMMUNITY MENTAL HEALTH CENTER CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	036089152	IL

General Provider Information

NPI Number	:	1003056557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KING COMMUNITY MENTAL HEALTH CENTER CORP

Provider Business Mailing Address
First Line	:	4455 S KING DRIVE
Second Line	:	SUITE 101
City	:	CHICAGO
State	:	IL
Zip	:	60653-3310
Country	:	US
Telephone Number	:	773-536-2700
Fax Number	:	773-751-2250

Provider Business Practice Location Address
First Line	:	4455 S KING DRIVE
Second Line	:	SUITE 101
City	:	CHICAGO
State	:	IL
Zip	:	60653-3310
Country	:	US
Telephone Number	:	773-536-2700
Fax Number	:	773-751-2250

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROUEEN RAFEYAN
Credential	:	MD
Telephone Number	:	773-536-2700

Provider Enumeration Date	:	02/24/2009
Last Update Date	:	06/25/2009

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