1114102530 NPI number — LAKE COUNTY PEDIATRICS SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114102530 NPI number — LAKE COUNTY PEDIATRICS SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE COUNTY PEDIATRICS SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114102530
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 S GREENLEAF AVE
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
GURNEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-336-0770
Provider Business Mailing Address Fax Number:
847-336-0159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 S GREENLEAF AVE
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
GURNEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-336-0770
Provider Business Practice Location Address Fax Number:
847-336-0159
Provider Enumeration Date:
01/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TANQUILUT
Authorized Official First Name:
MARLENE
Authorized Official Middle Name:
JUCO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-336-0770

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com