Healthcare Provider Details

I. General information

NPI: 1861229197
Provider Name (Legal Business Name): SUREGUARD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TIFFANY PT STE 110
BLOOMINGDALE IL
60108-2915
US

IV. Provider business mailing address

3414 GANNETT ST
HOUSTON TX
77025-3712
US

V. Phone/Fax

Practice location:
  • Phone: 630-924-1160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEE BROCHSTEIN
Title or Position: EXECTIVE DIRECTOR OF CORPORATE OPS
Credential:
Phone: 713-703-8642