Healthcare Provider Details

I. General information

NPI: 1689190951
Provider Name (Legal Business Name): VIRGINIA LACKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 08/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 W EVERGREEN AVE STE 404
CHICAGO IL
60642-7113
US

IV. Provider business mailing address

811 W EVERGREEN AVE STE 404
CHICAGO IL
60642-7113
US

V. Phone/Fax

Practice location:
  • Phone: 312-242-1665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070.023010
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: