Healthcare Provider Details

I. General information

NPI: 1679742316
Provider Name (Legal Business Name): LAKE FOREST ENDOSCOPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 E BELVIDERE RD SUITE 303
GRAYSLAKE IL
60030-2012
US

IV. Provider business mailing address

1475 E BELVIDERE RD SUITE 303
GRAYSLAKE IL
60030-2012
US

V. Phone/Fax

Practice location:
  • Phone: 219-789-9176
  • Fax:
Mailing address:
  • Phone: 219-789-9176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. TAMMY HAM
Title or Position: DIRECTOR
Credential:
Phone: 816-877-2005