Provider Demographics
NPI:1568262525
Name:KINNEY, CHARLES JR
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:KINNEY
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 DAVISON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60433-1369
Mailing Address - Country:US
Mailing Address - Phone:815-540-2875
Mailing Address - Fax:
Practice Address - Street 1:112 W PARK ST APT 1E
Practice Address - Street 2:
Practice Address - City:ELWOOD
Practice Address - State:IL
Practice Address - Zip Code:60421-9628
Practice Address - Country:US
Practice Address - Phone:815-540-2875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251V00000X
IL311ZA0620X, 372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372500000XNursing Service Related ProvidersChore ProviderGroup - Single Specialty
No251V00000XAgenciesVoluntary or Charitable
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home