Healthcare Provider Details

I. General information

NPI: 1679718977
Provider Name (Legal Business Name): LAKE COUNTY NEUROMONITORING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 S MILWAUKEE AVENUE
LIBERTYVILLE IL
60048
US

IV. Provider business mailing address

712 S MILWAUKEE AVENUE
LIBERTYVILLE IL
60048
US

V. Phone/Fax

Practice location:
  • Phone: 847-362-1848
  • Fax: 847-362-3351
Mailing address:
  • Phone: 847-362-1848
  • Fax: 847-362-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036082394
License Number StateIL

VIII. Authorized Official

Name: JONATHAN S CITOW
Title or Position: OWNER
Credential:
Phone: 847-362-1848