Provider Demographics
NPI:1356945935
Name:MONGIN, ALAN JOSEPH
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:JOSEPH
Last Name:MONGIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 COMMERCE DR STE 275
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3594
Mailing Address - Country:US
Mailing Address - Phone:847-420-8786
Mailing Address - Fax:
Practice Address - Street 1:333 COMMERCE DR STE 275
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3594
Practice Address - Country:US
Practice Address - Phone:847-420-8786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel
Provider Identifiers
StateIdentifier IDID TypeIssuer
1720530603OtherNPI