1871308999 NPI number — LAKE FOREST REGENESIS MEDICAL CENTER, PLLC

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 1871308999 NPI number — LAKE FOREST REGENESIS MEDICAL CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE FOREST REGENESIS MEDICAL CENTER, PLLC
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:
1871308999
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 W EVERETT RD STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE FOREST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60045-2668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
224-436-8006
Provider Business Mailing Address Fax Number:
949-703-8371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 W EVERETT RD STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE FOREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60045-2668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
224-436-8006
Provider Business Practice Location Address Fax Number:
949-703-8371
Provider Enumeration Date:
02/07/2025

Additional Information

Authorized Official

Authorized Official Last Name:
BUSH
Authorized Official First Name:
ALLANA
Authorized Official Middle Name:
KATHLEEN
Authorized Official Title or Position:
FNP-C
Authorized Official Telephone Number:
224-436-8006

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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