Provider Demographics
NPI:1720629041
Name:MONTE NIDO ILLINOIS, LLC
Entity Type:Organization
Organization Name:MONTE NIDO ILLINOIS, LLC
Other - Org Name:CLEMENTINE NAPERVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-663-1876
Mailing Address - Street 1:6100 SW 76TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5002
Mailing Address - Country:US
Mailing Address - Phone:305-663-1876
Mailing Address - Fax:
Practice Address - Street 1:27W121 80TH ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60565-1270
Practice Address - Country:US
Practice Address - Phone:305-663-1876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-08
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health