Healthcare Provider Details

I. General information

NPI: 1932672391
Provider Name (Legal Business Name): RESILIENCE HEALTHCARE- LAKEFRONT MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 ERIE CT
OAK PARK IL
60302-2519
US

IV. Provider business mailing address

4646 N MARINE DR
CHICAGO IL
60640-5759
US

V. Phone/Fax

Practice location:
  • Phone: 708-763-1490
  • Fax:
Mailing address:
  • Phone: 773-878-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MANOJ PRASAD
Title or Position: CEO
Credential:
Phone: 708-763-6700