Healthcare Provider Details

I. General information

NPI: 1801190525
Provider Name (Legal Business Name): SPINE & JOINT INSTITUTE OF LAKE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2634 GRAND AVE STE 100
WAUKEGAN IL
60085-2459
US

IV. Provider business mailing address

2634 GRAND AVE SUITE 100
WAUKEGAN IL
60085-2458
US

V. Phone/Fax

Practice location:
  • Phone: 847-775-0800
  • Fax: 847-775-0888
Mailing address:
  • Phone: 847-775-0800
  • Fax: 847-775-0888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number038010349
License Number StateIL

VIII. Authorized Official

Name: MR. GORDON SETO
Title or Position: CLINIC DIRECTOR
Credential:
Phone: 847-775-0800