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General NPI Number Information
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NPI Number | 1306465786
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Entity Type | Organization
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Legal Business Name | BRIGHTLIFE REGENERATIVE MEDICAL CLINIC LOMBARD SC
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Dates
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Enumeration Date | 04/15/2020
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Last Update Date | 04/17/2020
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Provider Practice Location Address
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Address Line | 442 E ROOSEVELT RD
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City | LOMBARD
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State | IL
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Zip | 60148-4630
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Country | US
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Telephone | 630-261-0001
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Fax |
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Provider Business Mailing Address
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Address Line | 442 E ROOSEVELT RD
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City | LOMBARD
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State | IL
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Zip | 60148-4630
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Country | US
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Telephone | 630-261-0001
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | STEVEN BURLISON
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Credential |
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Telephone | 630-261-0001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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