Healthcare Provider Details

I. General information

NPI: 1740728500
Provider Name (Legal Business Name): ENTOURAGE CLINICAL SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

697 S LAKE ST
MUNDELEIN IL
60060-3658
US

IV. Provider business mailing address

37 BURNETT AVE
LAKE VILLA IL
60046-8670
US

V. Phone/Fax

Practice location:
  • Phone: 847-406-0789
  • Fax:
Mailing address:
  • Phone: 847-393-5646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code174V00000X
TaxonomyClinical Ethicist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. MELANIE E DILLON
Title or Position: PRESIDENT
Credential: LCPC, NCC, CADC
Phone: 847-393-5646