Provider Demographics
NPI:1235257460
Name:MINDCARE PHYSICAL MEDICINE & REHAB CLINIC, INC.
Entity Type:Organization
Organization Name:MINDCARE PHYSICAL MEDICINE & REHAB CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:UDOETUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-756-1775
Mailing Address - Street 1:1010 DIXIE HWY STE 308
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-2666
Mailing Address - Country:US
Mailing Address - Phone:708-756-1775
Mailing Address - Fax:708-756-1780
Practice Address - Street 1:1010 DIXIE HWY STE 308
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2666
Practice Address - Country:US
Practice Address - Phone:708-756-1775
Practice Address - Fax:708-756-1780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL637100Medicare ID - Type UnspecifiedMEDICARE PROVIDER #