Healthcare Provider Details

I. General information

NPI: 1891467460
Provider Name (Legal Business Name): 996
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N WABASH AVE STE 1116-LM
CHICAGO IL
60602-1903
US

IV. Provider business mailing address

111 N WABASH AVE STE 1116-LM
CHICAGO IL
60602-1903
US

V. Phone/Fax

Practice location:
  • Phone: 312-800-3395
  • Fax: 866-776-7795
Mailing address:
  • Phone: 312-809-8380
  • Fax: 866-776-7795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. ARAM HONORE
Title or Position: LAB DIRECTOR
Credential: PHLEBOTOMIST
Phone: 312-809-8380