Healthcare Provider Details

I. General information

NPI: 1538356233
Provider Name (Legal Business Name): LAKE SHORE THERAPY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2338 W MORSE AVE 1 A
CHICAGO IL
60645-4767
US

IV. Provider business mailing address

2338 W MORSE AVE 1A
CHICAGO IL
60645-4767
US

V. Phone/Fax

Practice location:
  • Phone: 773-754-0027
  • Fax: 773-754-0063
Mailing address:
  • Phone: 773-754-0027
  • Fax: 773-754-0063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036-084312
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070013870
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number036-084312
License Number StateIL

VIII. Authorized Official

Name: DR. ELIZA DIACONESCU
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 773-754-0027