1447449616 NPI number — EVERGREEN CARE CENTER LTD

Table of content: DR. MIKAYLA LAWRENCE PT, DPT (NPI 1669280111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447449616 NPI number — EVERGREEN CARE CENTER LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN CARE CENTER LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447449616
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9760 S KEDZIE AVE
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
EVERGREEN PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60805-3109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-423-6209
Provider Business Mailing Address Fax Number:
708-423-9021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9760 S KEDZIE AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
EVERGREEN PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60805-3109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-423-6209
Provider Business Practice Location Address Fax Number:
708-423-9021
Provider Enumeration Date:
10/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOSEPH
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
708-423-6209

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DA0131 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036084895 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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