Healthcare Provider Details

I. General information

NPI: 1346530201
Provider Name (Legal Business Name): IMPALA EXPRESS CLINICAL LABORATORY SERVICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N MICHIGAN AVE STE 944E 845 N. MICHIGAN AVE, SUITE # 944-E
CHICAGO IL
60611-2213
US

IV. Provider business mailing address

845 N MICHIGAN AVE STE 944E 845 N. MICHIGAN AVE, SUITE # 944-E
CHICAGO IL
60611-2213
US

V. Phone/Fax

Practice location:
  • Phone: 312-202-0328
  • Fax: 312-202-0320
Mailing address:
  • Phone: 312-202-0328
  • Fax: 312-202-0320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number14D2018991
License Number StateIL

VIII. Authorized Official

Name: MR. ALEMAYEHU M GEBRESELLASSIE
Title or Position: PRESIDENT
Credential:
Phone: 847-951-5168