Healthcare Provider Details

I. General information

NPI: 1922292291
Provider Name (Legal Business Name): NBHC NCTC INPR GREAT LAKES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 6TH ST STE A
GREAT LAKES IL
60088-2833
US

IV. Provider business mailing address

3001 6TH ST STE A
GREAT LAKES IL
60088-2833
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-4560
  • Fax:
Mailing address:
  • Phone: 847-688-4560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DUWAYNE BROZEK
Title or Position: COMPTOLLER
Credential:
Phone: 847-688-2888