Provider Demographics
NPI:1326280462
Name:LORETTA L BAYLESS
Entity Type:Organization
Organization Name:LORETTA L BAYLESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAYLESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-962-4415
Mailing Address - Street 1:15813 CLIFTON PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MARKHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60428-3920
Mailing Address - Country:US
Mailing Address - Phone:312-962-4415
Mailing Address - Fax:708-234-7348
Practice Address - Street 1:15813 CLIFTON PARK AVE
Practice Address - Street 2:
Practice Address - City:MARKHAM
Practice Address - State:IL
Practice Address - Zip Code:60428-3920
Practice Address - Country:US
Practice Address - Phone:312-962-4415
Practice Address - Fax:708-234-7348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL9737286347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle