1467585075 NPI number — NORTHWEST TREATMENT ASSOCIATES, INC.

Table of content: JUAN CARLOS CONDE D.C. (NPI 1831260660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467585075 NPI number — NORTHWEST TREATMENT ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST TREATMENT ASSOCIATES, INC.
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:
1467585075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
645 MCHENRY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60098-2922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-337-1234
Provider Business Mailing Address Fax Number:
815-337-5653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
645 MCHENRY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60098-2922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-337-1234
Provider Business Practice Location Address Fax Number:
815-337-5653
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FETZNER
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
815-337-1234

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  180 000371 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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