| Defined Lj, Inc | |
|
2623 N Clark St Chicago IL 60614-1524 | |
| (312) 722-6977 | |
| Not Available |
| Full Name | Defined Lj, Inc |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 2623 N Clark St, Chicago, Illinois |
| Authorized Official Name and Position | Kenneth Munnerlyn (PRESIDENT) |
| Authorized Official Contact | 7737307374 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Defined Lj, Inc 2623 N Clark St Chicago IL 60614-1524 Ph: (123) 722-6977 | Defined Lj, Inc 2623 N Clark St Chicago IL 60614-1524 Ph: (312) 722-6977 |
| NPI Number | 1497419261 |
|---|---|
| Provider Enumeration Date | 10/27/2021 |
| Last Update Date | 09/29/2023 |
| Certification Date | 09/29/2023 |
| Medicare PECOS PAC ID | 7012361165 |
|---|---|
| Medicare Enrollment ID | O20230925000427 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1497419261 | NPI | - | NPPES |
| Provider Name | Jimmy Viet Ninh |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1104088939 PECOS PAC ID: 6608913835 Enrollment ID: I20110204000220 |
| Provider Name | Natalie Hindley |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1669820791 PECOS PAC ID: 5092009654 Enrollment ID: I20160805000149 |
| Provider Name | Krystle M. Graham |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1720757198 PECOS PAC ID: 2668867763 Enrollment ID: I20220325002062 |
| Provider Name | Sydney Mitchell |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1740069582 PECOS PAC ID: 9931558087 Enrollment ID: I20231214000984 |
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