Provider Demographics
NPI:1386132520
Name:ITAC MEDICAL SUPPLY COMPANY, LLC
Entity type:Organization
Organization Name:ITAC MEDICAL SUPPLY COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHIQUITA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-340-8826
Mailing Address - Street 1:9449 S KEDZIE AVE STE 357
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2325
Mailing Address - Country:US
Mailing Address - Phone:312-340-8826
Mailing Address - Fax:
Practice Address - Street 1:5113 S. HARPER AVE
Practice Address - Street 2:STE. 2C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615
Practice Address - Country:US
Practice Address - Phone:312-340-8826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherDME