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General NPI Number Information
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NPI Number | 1306662853
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Entity Type | Individual
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Provider Name | DEMETRIC LOVE RT(R)
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Gender | Male
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Dates
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Enumeration Date | 12/02/2024
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Last Update Date | 12/02/2024
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Provider Practice Location Address
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Address Line | 12251 S 80TH AVE
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City | PALOS HEIGHTS
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State | IL
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Zip | 60463-1290
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Country | US
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Telephone | 708-923-8257
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Fax |
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Provider Business Mailing Address
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Address Line | 5346 NORTHWESTERN DR
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City | MATTESON
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State | IL
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Zip | 60443-1676
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Country | US
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Telephone | 708-691-4449
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 500482568
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License Number State | IL
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