Provider Demographics
NPI:1518210327
Name:VILLAGE DERMATOLOGY, SC
Entity Type:Organization
Organization Name:VILLAGE DERMATOLOGY, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CECELIA
Authorized Official - Middle Name:H
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-920-9177
Mailing Address - Street 1:401 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2844
Mailing Address - Country:US
Mailing Address - Phone:847-920-9177
Mailing Address - Fax:847-920-9188
Practice Address - Street 1:401 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2844
Practice Address - Country:US
Practice Address - Phone:847-920-9177
Practice Address - Fax:847-920-9188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042619944261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center