Healthcare Provider Details

I. General information

NPI: 1245165497
Provider Name (Legal Business Name): CHARLES LAWRENCE III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3643 GREEN ST
STEGER IL
60475-1629
US

IV. Provider business mailing address

3643 GREEN ST
STEGER IL
60475-1629
US

V. Phone/Fax

Practice location:
  • Phone: 773-797-7165
  • Fax:
Mailing address:
  • Phone: 773-797-7165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberG4G4L7H4
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: