Healthcare Provider Details

I. General information

NPI: 1487693511
Provider Name (Legal Business Name): LATA JAIN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LATA BAKLIWAL

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 S MICHIGAN AVE STE 2212
CHICAGO IL
60603-3335
US

IV. Provider business mailing address

2665 N HARTLAND CT
CHICAGO IL
60614-4960
US

V. Phone/Fax

Practice location:
  • Phone: 312-346-1136
  • Fax: 312-853-2293
Mailing address:
  • Phone: 847-452-9659
  • Fax: 773-303-8297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number147001053
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: