MEDICARE: CAMBODIAN ASSOCIATION OF ILLINOIS

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	253Z00000X	In Home Supportive Care Agency	INH1012030	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538508601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMBODIAN ASSOCIATION OF ILLINOIS

Provider Business Mailing Address
First Line	:	2831 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3619
Country	:	US
Telephone Number	:	773-878-7090
Fax Number	:	773-878-5299

Provider Business Practice Location Address
First Line	:	2831 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3619
Country	:	US
Telephone Number	:	773-878-7090
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. KOMPHA SETH
Credential	:
Telephone Number	:	773-878-7090

Provider Enumeration Date	:	06/21/2013
Last Update Date	:	08/15/2014

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