MEDICARE: THE METRO MENTORSHIP INITIATIVE

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	305R00000X	Preferred Provider Organization

General Provider Information

NPI Number	:	1417310335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE METRO MENTORSHIP INITIATIVE

Provider Business Mailing Address
First Line	:	1828 N LOWELL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-4818
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1828 N LOWELL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-4818
Country	:	US
Telephone Number	:	773-595-4645
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LORNE MASSIE
Credential	:
Telephone Number	:	773-595-4645

Provider Enumeration Date	:	03/29/2016
Last Update Date	:	03/29/2016

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Directions to “THE METRO MENTORSHIP INITIATIVE ” Practice Location

Language	Start Address	Practice Location

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