Basic Information
| Provider Information | |||||||||
| NPI: | 1477991891 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JENCARE NEIGHBORHOOD MEDICAL CENTER GLENWOOD, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 PARK CENTRE BLVD | ||||||||
| Address2: | SUITE 136 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695373 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 19310 S HALSTED ST | ||||||||
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| City: | GLENWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604251562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2013 | ||||||||
| LastUpdateDate: | 12/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | CHEN | ||||||||
| AuthorizedOfficialFirstName: | GORDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3056286117 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 036.131322 | IL | N | Suppliers | Non-Pharmacy Dispensing Site | 174400000X | 036.131322 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.