MEDICARE: CENTRO MEDICO LA VILLITA S.C.

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	207Q00000X	Family Medicine Physician		IL

General Provider Information

NPI Number	:	1457554404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO MEDICO LA VILLITA S.C.

Provider Business Mailing Address
First Line	:	3356 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-4037
Country	:	US
Telephone Number	:	773-522-7240
Fax Number	:	773-522-1343

Provider Business Practice Location Address
First Line	:	3356 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-4037
Country	:	US
Telephone Number	:	773-522-7240
Fax Number	:	773-522-1343

Authorized Official
Title or Position	:	MEDICAL ASSISTANT
Name	:	CARMEN MATCHAIN
Credential	:	M.A.
Telephone Number	:	773-522-7240

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	08/22/2020

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