Healthcare Provider Details

I. General information

NPI: 1750443073
Provider Name (Legal Business Name): KRISTI LYN KOZLOV LLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 OGDEN AVE
LISLE IL
60532-1603
US

IV. Provider business mailing address

650 SPRING HILL RING RD STE 2020
WEST DUNDEE IL
60118-1297
US

V. Phone/Fax

Practice location:
  • Phone: 630-527-1920
  • Fax: 630-527-0125
Mailing address:
  • Phone: 312-771-2007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036103302
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: