Provider Demographics
NPI:1235461278
Name:CLINICA SU RED
Entity type:Organization
Organization Name:CLINICA SU RED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:RHODE
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:708-337-7704
Mailing Address - Street 1:5241 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-4967
Mailing Address - Country:US
Mailing Address - Phone:708-364-8441
Mailing Address - Fax:708-364-8443
Practice Address - Street 1:720 COLLINS ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-1615
Practice Address - Country:US
Practice Address - Phone:815-726-2288
Practice Address - Fax:815-726-2814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty