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General NPI Number Information
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NPI Number | 1720452709
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Entity Type | Individual
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Provider Name | DONALD HANSEN OWNER
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Gender | Male
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Dates
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Enumeration Date | 11/13/2015
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Last Update Date | 11/13/2015
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Provider Practice Location Address
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Address Line | 541 SPRUCE RD
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City | BOLINGBROOK
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State | IL
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Zip | 60440-2504
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Country | US
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Telephone | 630-750-7378
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Fax | 630-929-8057
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Provider Business Mailing Address
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Address Line | 541 SPRUCE RD
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City | BOLINGBROOK
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State | IL
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Zip | 60440-2504
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Country | US
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Telephone | 630-750-7378
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Fax | 630-929-8057
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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 | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 14D2099042
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License Number State | IL
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