MEDICARE: COREY MITCHELL

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	171WH0202X	Home Modifications Contractor

General Provider Information

NPI Number	:	1811435779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY MITCHELL

Provider Business Mailing Address
First Line	:	4528 S EVANS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-3521
Country	:	US
Telephone Number	:	312-856-7251
Fax Number	:

Provider Business Practice Location Address
First Line	:	4528 S EVANS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-3521
Country	:	US
Telephone Number	:	312-856-7251
Fax Number	:

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

Provider Enumeration Date	:	02/10/2017
Last Update Date	:	02/10/2017

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Directions to “ COREY MITCHELL ” Practice Location

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