Provider Demographics
NPI:1336580026
Name:PRESENCE AMBULATORY SERVICE
Entity type:Organization
Organization Name:PRESENCE AMBULATORY SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MELVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-914-2417
Mailing Address - Street 1:1000 REMINGTON BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-5114
Mailing Address - Country:US
Mailing Address - Phone:630-914-2417
Mailing Address - Fax:630-914-2499
Practice Address - Street 1:1625 SHERIDAN RD
Practice Address - Street 2:SUITE 1A
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1824
Practice Address - Country:US
Practice Address - Phone:847-256-2890
Practice Address - Fax:847-256-2802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation