Provider Demographics
NPI:1164567426
Name:WINDY CITY MEDICAL CLINIC A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:WINDY CITY MEDICAL CLINIC A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-957-7510
Mailing Address - Street 1:PO BOX 1946
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92312-1946
Mailing Address - Country:US
Mailing Address - Phone:760-255-2400
Mailing Address - Fax:760-957-7517
Practice Address - Street 1:525 MELISSA AVE STE A
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3002
Practice Address - Country:US
Practice Address - Phone:760-255-2400
Practice Address - Fax:760-957-7517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G778041Medicaid
CAZZZ07612ZMedicare PIN
CA00G778041Medicaid
CA00G778042Medicare PIN