Provider Demographics
NPI:1801617923
Name:MACCHIA, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:MACCHIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 E QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2175
Mailing Address - Country:US
Mailing Address - Phone:708-785-5515
Mailing Address - Fax:
Practice Address - Street 1:120 OAKBROOK CENTER MALL STE 216
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-4713
Practice Address - Country:US
Practice Address - Phone:630-571-5470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL220.000051247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other