Healthcare Provider Details

I. General information

NPI: 1588484083
Provider Name (Legal Business Name): FAIS REFERENCE LABS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 03/05/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 BROWN BLVD STE 103
BOURBONNAIS IL
60914-2325
US

IV. Provider business mailing address

475 BROWN BLVD STE 103
BOURBONNAIS IL
60914-2325
US

V. Phone/Fax

Practice location:
  • Phone: 815-936-8962
  • Fax: 815-936-8650
Mailing address:
  • Phone: 815-936-8962
  • Fax: 815-936-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: KRISTY FARMER
Title or Position: OFFICE MANAGER
Credential:
Phone: 815-937-7962