Healthcare Provider Details

I. General information

NPI: 1497419261
Provider Name (Legal Business Name): DEFINED LJ, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2623 N CLARK ST
CHICAGO IL
60614-1524
US

IV. Provider business mailing address

2623 N CLARK ST
CHICAGO IL
60614-1524
US

V. Phone/Fax

Practice location:
  • Phone: 312-722-6977
  • Fax:
Mailing address:
  • Phone: 123-722-6977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KENNETH MUNNERLYN
Title or Position: PRESIDENT
Credential: MD
Phone: 773-730-7374