Healthcare Provider Details

I. General information

NPI: 1154294502
Provider Name (Legal Business Name): CLINICAL DIAGNOSTIC LABS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2025
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4652 OAKTON ST
SKOKIE IL
60076-3145
US

IV. Provider business mailing address

4652 OAKTON ST
SKOKIE IL
60076-3145
US

V. Phone/Fax

Practice location:
  • Phone: 708-529-5659
  • Fax: 708-529-5885
Mailing address:
  • Phone: 708-529-5659
  • Fax: 708-529-5885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: ANSAR A MOHAMMED
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 773-852-7866