MEDICARE: MAONEKEEKEPOBA GWAN

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	156F00000X	Technician/Technologist

General Provider Information

NPI Number	:	1730936220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAONEKEEKEPOBA GWAN

Provider Business Mailing Address
First Line	:	1431 MCHENRY RD STE 105
Second Line	:
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-1378
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1431 MCHENRY RD STE 105
Second Line	:
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-1378
Country	:	US
Telephone Number	:	708-892-2900
Fax Number	:

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

Provider Enumeration Date	:	05/02/2024
Last Update Date	:	05/02/2024

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