MEDICARE: SHOTFAIRY.COM 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	251J00000X	Nursing Care Agency	4000255	IL

General Provider Information

NPI Number	:	1487987517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOTFAIRY.COM LLC

Provider Business Mailing Address
First Line	:	PO BOX 166593
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-6593
Country	:	US
Telephone Number	:	312-328-7468
Fax Number	:

Provider Business Practice Location Address
First Line	:	3135 S GILES AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3937
Country	:	US
Telephone Number	:	312-328-7468
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF HUMAN RESOURCES
Name	:	MRS. COLLEEN HANLON
Credential	:
Telephone Number	:	312-328-7468

Provider Enumeration Date	:	09/08/2009
Last Update Date	:	09/08/2009

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