Healthcare Provider Details

I. General information

NPI: 1790437366
Provider Name (Legal Business Name): ELGIN LAB DIAGNOSTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 W GRAND AVE STE R
BENSENVILLE IL
60106-3365
US

IV. Provider business mailing address

1339 N ARTESIAN AVE APT 2
CHICAGO IL
60622-6962
US

V. Phone/Fax

Practice location:
  • Phone: 708-581-8304
  • Fax: 877-389-7885
Mailing address:
  • Phone: 206-234-7715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MR. MUHAMMAD NAZIR
Title or Position: ADMINISTRATOR
Credential: ADMINISTRATOR
Phone: 708-581-8304