MEDICARE: LAEEQ RAI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory
2	291U00000X	Clinical Medical Laboratory		IL

General Provider Information

NPI Number	:	1396492716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAEEQ RAI

Provider Business Mailing Address
First Line	:	1 S WOLF RD STE B
Second Line	:
City	:	PROSPECT HEIGHTS
State	:	IL
Zip	:	60070-2628
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 S WOLF RD STE B
Second Line	:
City	:	PROSPECT HEIGHTS
State	:	IL
Zip	:	60070-2628
Country	:	US
Telephone Number	:	773-870-7012
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2022
Last Update Date	:	03/05/2022

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Directions to “ LAEEQ RAI ” Practice Location

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