Healthcare Provider Details

I. General information

NPI: 1912445800
Provider Name (Legal Business Name): ALLURE SKIN AND LASER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2017
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E LAKE STREET
ADDISON IL
60101
US

IV. Provider business mailing address

832 ROSEMARY TER
DEERFIELD IL
60015
US

V. Phone/Fax

Practice location:
  • Phone: 630-818-7546
  • Fax:
Mailing address:
  • Phone: 224-805-8713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209015215
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. TERRAH KOPPIE GAVRILOS
Title or Position: NURSE PRACTITIONER
Credential: D.N.P.
Phone: 22480587113