Healthcare Provider Details

I. General information

NPI: 1821526328
Provider Name (Legal Business Name): ABC LABS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2017
Last Update Date: 05/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6449 S PULASKI RD STE 108
CHICAGO IL
60629-5148
US

IV. Provider business mailing address

6449 S PULASKI RD STE 108
CHICAGO IL
60629-5148
US

V. Phone/Fax

Practice location:
  • Phone: 773-306-1259
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number14D2118590
License Number StateIL

VIII. Authorized Official

Name: SHAHIDA REHMAN
Title or Position: OWNER
Credential:
Phone: 708-289-6328