MEDICARE: DIVERSEY HEALTH CARE CLINIC INC

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	261QP2300X	Primary Care Clinic/Center	036.120095	IL

General Provider Information

NPI Number	:	1225416308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSEY HEALTH CARE CLINIC INC

Provider Business Mailing Address
First Line	:	349 BUCKINGHAM CT
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-1667
Country	:	US
Telephone Number	:	708-738-7351
Fax Number	:

Provider Business Practice Location Address
First Line	:	4911 W DIVERSEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1705
Country	:	US
Telephone Number	:	773-237-3100
Fax Number	:	855-299-4948

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICARDO MACHADO
Credential	:	M.D
Telephone Number	:	708-738-7351

Provider Enumeration Date	:	05/11/2015
Last Update Date	:	08/21/2015

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