=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487852679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY NEUROLOGIC CENTER SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2007
-----------------------------------------------------
Last Update Date | 09/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2172 BLACKBERRY DR SUITE 202
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60134-1073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-208-7735
-----------------------------------------------------
Fax | 630-208-6956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2172 BLACKBERRY DR SUITE 202
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60134-1073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-208-7735
-----------------------------------------------------
Fax | 630-208-6956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MR. BORIS LAKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-208-7735
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 036-093008
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------