Provider Demographics
NPI:1225416308
Name:DIVERSEY HEALTH CARE CLINIC INC
Entity Type:Organization
Organization Name:DIVERSEY HEALTH CARE CLINIC INC
Other - Org Name:DIVERSEY HEALTHCARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:MACHADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-738-7351
Mailing Address - Street 1:349 BUCKINGHAM CT
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-1667
Mailing Address - Country:US
Mailing Address - Phone:708-738-7351
Mailing Address - Fax:
Practice Address - Street 1:4911 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1705
Practice Address - Country:US
Practice Address - Phone:773-237-3100
Practice Address - Fax:855-299-4948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.120095261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care