MEDICARE: MARY KAY YARAK

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	320700000X	Physical Disabilities Residential Treatment Facility	057.003810	IL

General Provider Information

NPI Number	:	1790150340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KAY YARAK

Provider Business Mailing Address
First Line	:	1537 N WASHTENAW AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-1636
Country	:	US
Telephone Number	:	773-252-8684
Fax Number	:

Provider Business Practice Location Address
First Line	:	1537 N WASHTENAW AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-1636
Country	:	US
Telephone Number	:	773-252-8684
Fax Number	:

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

Provider Enumeration Date	:	12/08/2015
Last Update Date	:	12/08/2015

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