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General NPI Number Information
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NPI Number | 1497419261
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Entity Type | Organization
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Legal Business Name | DEFINED LJ, INC
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Dates
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Enumeration Date | 10/27/2021
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Last Update Date | 09/29/2023
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Provider Practice Location Address
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Address Line | 2623 N CLARK ST
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City | CHICAGO
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State | IL
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Zip | 60614-1524
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Country | US
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Telephone | 312-722-6977
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Fax |
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Provider Business Mailing Address
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Address Line | 2623 N CLARK ST
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City | CHICAGO
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State | IL
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Zip | 60614-1524
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Country | US
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Telephone | 123-722-6977
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KENNETH MUNNERLYN
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Credential | MD
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Telephone | 773-730-7374
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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