Provider Demographics
NPI:1346434776
Name:WEST GRAND CLINIC,LTD
Entity Type:Organization
Organization Name:WEST GRAND CLINIC,LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIACCHINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-636-9544
Mailing Address - Street 1:1851 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622
Mailing Address - Country:US
Mailing Address - Phone:312-455-2801
Mailing Address - Fax:312-455-2802
Practice Address - Street 1:1851 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:312-455-2801
Practice Address - Fax:312-455-2802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty