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General NPI Number Information
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NPI Number | 1639346158
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Entity Type | Individual
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Provider Name | YURI KISILEVICH
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Gender | Male
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Dates
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Enumeration Date | 05/14/2008
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Last Update Date | 05/14/2008
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Provider Practice Location Address
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Address Line | 654 N BANK LN
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City | LAKE FOREST
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State | IL
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Zip | 60045-1811
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Country | US
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Telephone | 847-234-6541
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Fax |
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Provider Business Mailing Address
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Address Line | 654 BANK LANE
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City | LAKE FOREST
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State | IL
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Zip | 60045
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Country | US
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Telephone | 847-234-6541
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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 | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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