Basic Information
| Provider Information | |||||||||
| NPI: | 1972080992 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY CARE SC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2320 W PETERSON AVE FL 6 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606595242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735089800 | ||||||||
| FaxNumber: | 7735081796 | ||||||||
| Practice Location | |||||||||
| Address1: | 2320 W PETERSON AVE FL 6 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606595242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735089800 | ||||||||
| FaxNumber: | 7735081796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2018 | ||||||||
| LastUpdateDate: | 07/23/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SENNO | ||||||||
| AuthorizedOfficialFirstName: | AREF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7735089800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.