Healthcare Provider Details

I. General information

NPI: 1457711269
Provider Name (Legal Business Name): LAKE COUNTY VEIN SPECIALISTS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 N HUNT CLUB RD SUITE 202
GURNEE IL
60031-2632
US

IV. Provider business mailing address

1425 N HUNT CLUB RD SUITE 202
GURNEE IL
60031-2632
US

V. Phone/Fax

Practice location:
  • Phone: 630-928-5234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State

VIII. Authorized Official

Name: DANA GRAY
Title or Position: MD
Credential:
Phone: 630-928-5234