Provider Demographics
NPI:1134540446
Name:FAMILY PRIMARY CARE CLINIC
Entity type:Organization
Organization Name:FAMILY PRIMARY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:TASIGCHANA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:224-381-7672
Mailing Address - Street 1:2424 WASHINGTON ST STE 208
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-5077
Mailing Address - Country:US
Mailing Address - Phone:224-381-7672
Mailing Address - Fax:224-381-7969
Practice Address - Street 1:2424 WASHINGTON ST STE 208
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5077
Practice Address - Country:US
Practice Address - Phone:224-381-7672
Practice Address - Fax:224-381-7969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-04
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.009079261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care