Healthcare Provider Details

I. General information

NPI: 1780179911
Provider Name (Legal Business Name): ELIZABETH MARIE GAVIN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 DUNDEE RD
NORTHBROOK IL
60062-2422
US

IV. Provider business mailing address

1137 CHURCH ST
GLENVIEW IL
60025-2928
US

V. Phone/Fax

Practice location:
  • Phone: 847-421-8939
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198001258
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: