Provider Demographics
NPI:1780631317
Name:HINES VAMC
Entity Type:Organization
Organization Name:HINES VAMC
Other - Org Name:BOURBONNAIS VA CBOC
Other - Org Type:Other Name
Authorized Official - Title/Position:NPI TEAM
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-382-2579
Mailing Address - Street 1:PO BOX 94482
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-4482
Mailing Address - Country:US
Mailing Address - Phone:608-821-7200
Mailing Address - Fax:608-821-7658
Practice Address - Street 1:581 WILLIAM LATHAM DR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2317
Practice Address - Country:US
Practice Address - Phone:608-821-7200
Practice Address - Fax:608-821-7658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA