=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629518857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LICE CLINICS OF AMERICA-NORTH SHORE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2017
-----------------------------------------------------
Last Update Date | 03/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 LAKE COOK RD STE 201
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-4930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-282-4226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 LAKE COOK RD STE 201
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-4930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-282-4226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/TECHNICIAN
-----------------------------------------------------
Name | JILL LESHTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-282-4226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------