Provider Demographics
NPI:1285345678
Name:ANGELICA CORNEJO LLC
Entity type:Organization
Organization Name:ANGELICA CORNEJO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNEJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-331-4029
Mailing Address - Street 1:1318 W 107TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-3632
Mailing Address - Country:US
Mailing Address - Phone:773-331-4029
Mailing Address - Fax:
Practice Address - Street 1:10725 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-3217
Practice Address - Country:US
Practice Address - Phone:773-270-1042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health