Basic Information
| Provider Information | |||||||||
| NPI: | 1720321938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JENCARE NEIGHBORHOOD MEDICAL CENTER OAK LAWN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 PARK CENTRE BLVD STE 136 | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695373 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6101 W 95TH ST | ||||||||
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| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2013 | ||||||||
| LastUpdateDate: | 09/09/2013 | ||||||||
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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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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.