Provider Demographics
NPI:1679008734
Name:DR MEDA PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DR MEDA PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IZUCHUKWU
Authorized Official - Middle Name:
Authorized Official - Last Name:NWAFO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-378-8079
Mailing Address - Street 1:1215 N HUMPHREY AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 N HUMPHREY AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1111
Practice Address - Country:US
Practice Address - Phone:708-378-8079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119419251E00000X
405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty