Provider Demographics
NPI:1730701350
Name:STEPHANIE MADDEN LLC
Entity type:Organization
Organization Name:STEPHANIE MADDEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-631-1476
Mailing Address - Street 1:2675 W GRAND AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1158
Mailing Address - Country:US
Mailing Address - Phone:630-631-1476
Mailing Address - Fax:
Practice Address - Street 1:500 N DEARBORN ST STE 700
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3397
Practice Address - Country:US
Practice Address - Phone:630-631-1476
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service