MEDICARE: DISENTANGLE LLC

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	247200000X	Other Technician

General Provider Information

NPI Number	:	1134650484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DISENTANGLE LLC

Provider Business Mailing Address
First Line	:	11104 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2330
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11104 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2330
Country	:	US
Telephone Number	:	708-581-6487
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JACLYN O'CONNELL
Credential	:
Telephone Number	:	708-581-6487

Provider Enumeration Date	:	03/27/2017
Last Update Date	:	03/27/2017

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Directions to “DISENTANGLE LLC ” Practice Location

Language	Start Address	Practice Location

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