MEDICARE: ANDREA EUNICE BILLUPS COTA/L

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	172V00000X	Community Health Worker	057.001634	IL

General Provider Information

NPI Number	:	1679749162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA EUNICE BILLUPS COTA/L

Provider Business Mailing Address
First Line	:	4136 LAKEVIEW DR
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-5151
Country	:	US
Telephone Number	:	708-774-2550
Fax Number	:	708-991-2727

Provider Business Practice Location Address
First Line	:	4136 LAKEVIEW DR
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-5151
Country	:	US
Telephone Number	:	708-774-2550
Fax Number	:	708-991-2727

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	05/05/2008

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