MEDICARE: ADVANCE LAB COMPANY

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

General Provider Information

NPI Number	:	1427706852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCE LAB COMPANY

Provider Business Mailing Address
First Line	:	2359 W WALNUT ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612
Country	:	US
Telephone Number	:	773-563-1231
Fax Number	:

Provider Business Practice Location Address
First Line	:	2359 W WALNUT ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612
Country	:	US
Telephone Number	:	773-563-1231
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SYED MANNAN AHMED
Credential	:
Telephone Number	:	773-563-1231

Provider Enumeration Date	:	03/15/2022
Last Update Date	:	03/15/2022

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