Provider Demographics
NPI:1467820001
Name:3P4CARE (IL) LLC AVONDALE
Entity type:Organization
Organization Name:3P4CARE (IL) LLC AVONDALE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-654-1888
Mailing Address - Street 1:3502 N KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5622
Mailing Address - Country:US
Mailing Address - Phone:773-654-1888
Mailing Address - Fax:773-754-7412
Practice Address - Street 1:3502 N KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5622
Practice Address - Country:US
Practice Address - Phone:773-654-1888
Practice Address - Fax:773-754-7412
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:3P4CARE (IL) LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.094438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty