Healthcare Provider Details

I. General information

NPI: 1871870683
Provider Name (Legal Business Name): CHICAGO ANTI-AGING AND VEIN SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 TAMER LN
GLENVIEW IL
60025-3768
US

IV. Provider business mailing address

2921 W DEVON AVE
CHICAGO IL
60659-1507
US

V. Phone/Fax

Practice location:
  • Phone: 847-904-7500
  • Fax:
Mailing address:
  • Phone: 312-729-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.124097
License Number StateIL

VIII. Authorized Official

Name: LANA MOSHKOVICH
Title or Position: CMM, CPC, CEMC
Credential:
Phone: 847-904-7500