Provider Demographics
NPI:1063735413
Name:ADVANCE HEALTH PROVIDERS LLC
Entity type:Organization
Organization Name:ADVANCE HEALTH PROVIDERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:FAUSTINO
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:630-267-2627
Mailing Address - Street 1:2460 HANBURY LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-5049
Mailing Address - Country:US
Mailing Address - Phone:630-708-6941
Mailing Address - Fax:630-344-8100
Practice Address - Street 1:2460 HANBURY LN
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-5049
Practice Address - Country:US
Practice Address - Phone:630-708-6941
Practice Address - Fax:630-344-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-12
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.006796363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3767Medicare PIN