Organization
15 PARK PLACE LLC
Active
Organization
15 PARK PLACE LLC
Active
Other names
Adult Internal Medicine Office Practice
Organization subpart
No
Provider details
NPI number
Authorized official
CLARA AMPADU FNPC (CEO)
(618) 580-1359
Entity
Organization
Contact information
Practice address
15 PARK PL STE 1, SWANSEA, IL 62226-2918
(618) 580-1359
(618) 234-7242
Mailing address
15 PARK PL STE 1, SWANSEA, IL 62226-2918
(618) 580-1359
(618) 234-7242
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
363LP2300X
Primary Care Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0360832704
—
IL
Enumeration date
04/22/2020
Last updated
07/08/2020
Update your record
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