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General NPI Number Information
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NPI Number | 1740315332
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Entity Type | Organization
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Legal Business Name | SURGIACL ASSISTINGSERVICES OF LAKE COUNTY
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Dates
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Enumeration Date | 02/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2400 N SAMSON WAY APT#2D
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City | WAUKEGAN
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State | IL
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Zip | 60087-5079
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Country | US
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Telephone | 122-439-9931
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Fax | 224-944-0084
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Provider Business Mailing Address
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Address Line | 2400 N SAMSON WAY APT#2D
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City | WAUKEGAN
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State | IL
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Zip | 60087-5079
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Country | US
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Telephone | 122-439-9931
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Fax | 224-944-0084
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Authorized Official
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Title or Position | SURGICAL ASSISTANT
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Name | MR. KIM LADELL LUSTER
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Credential |
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Telephone | 12243999317
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZS0410X
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Taxonomy Name | Surgical Technologist
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License Number |
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License Number State | IL
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