Healthcare Provider Details

I. General information

NPI: 1114102530
Provider Name (Legal Business Name): LAKE COUNTY PEDIATRICS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S GREENLEAF AVE SUITE E
GURNEE IL
60031
US

IV. Provider business mailing address

200 S GREENLEAF AVE SUITE E
GURNEE IL
60031
US

V. Phone/Fax

Practice location:
  • Phone: 847-336-0770
  • Fax: 847-336-0159
Mailing address:
  • Phone: 847-336-0770
  • Fax: 847-336-0159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MARLENE JUCO TANQUILUT
Title or Position: PRESIDENT
Credential: MD
Phone: 847-336-0770