Provider Demographics
NPI:1447870274
Name:15 PARK PLACE LLC
Entity type:Organization
Organization Name:15 PARK PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMPADU
Authorized Official - Suffix:
Authorized Official - Credentials:FNPC
Authorized Official - Phone:618-580-1359
Mailing Address - Street 1:15 PARK PL STE 1
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2918
Mailing Address - Country:US
Mailing Address - Phone:618-580-1359
Mailing Address - Fax:618-234-7242
Practice Address - Street 1:15 PARK PL STE 1
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2918
Practice Address - Country:US
Practice Address - Phone:618-580-1359
Practice Address - Fax:618-234-7242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-22
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360832704Medicaid