Provider Demographics
NPI:1306231147
Name:TAKECARE CLINIC
Entity Type:Organization
Organization Name:TAKECARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARKET MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:224-500-7627
Mailing Address - Street 1:305 W ROLLINS RD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-1217
Mailing Address - Country:US
Mailing Address - Phone:224-338-3567
Mailing Address - Fax:847-546-3089
Practice Address - Street 1:305 W ROLLINS RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-1217
Practice Address - Country:US
Practice Address - Phone:224-338-3567
Practice Address - Fax:847-546-3089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008821305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1720373731Medicaid
IL1720373731Medicare PIN