Provider Demographics
NPI:1164687869
Name:CHARM DEVELOPMENT LLC
Entity Type:Organization
Organization Name:CHARM DEVELOPMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-503-1105
Mailing Address - Street 1:515 W 14TH ST
Mailing Address - Street 2:UNIT C
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-2456
Mailing Address - Country:US
Mailing Address - Phone:708-503-1105
Mailing Address - Fax:
Practice Address - Street 1:515 W 14TH ST
Practice Address - Street 2:UNIT C
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2456
Practice Address - Country:US
Practice Address - Phone:708-503-1105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036035802207Q00000X
IL335-0272312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036035802Medicaid
C40957Medicare UPIN
214139Medicare PIN