Provider Demographics
NPI:1629605712
Name:VENVISOR HEALTH ILLINOIS LLC
Entity Type:Organization
Organization Name:VENVISOR HEALTH ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF REGIONAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JACKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-567-5243
Mailing Address - Street 1:PO BOX 2533
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-8533
Mailing Address - Country:US
Mailing Address - Phone:203-567-5243
Mailing Address - Fax:
Practice Address - Street 1:1333 BURR RIDGE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0833
Practice Address - Country:US
Practice Address - Phone:203-567-5243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-26
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty