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General NPI Number Information
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NPI Number | 1760750665
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Entity Type | Organization
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Legal Business Name | LONG TERM CARE LABORATORY, LLC.
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Dates
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Enumeration Date | 12/06/2011
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Last Update Date | 08/08/2013
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Provider Practice Location Address
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Address Line | 2458 ELMHURST RD
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City | ELK GROVE VILLAGE
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State | IL
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Zip | 60007-6311
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Country | US
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Telephone | 630-422-7800
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Fax | 630-422-1360
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Provider Business Mailing Address
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Address Line | 2458 ELMHURST RD
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City | ELK GROVE VILLAGE
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State | IL
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Zip | 60007-6311
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Country | US
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Telephone | 630-422-7800
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Fax | 630-422-1360
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Authorized Official
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Title or Position | ADMINSTRATOR
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Name | DR. SAM SHIMI
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Credential |
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Telephone | 630-422-7802
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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 | 14D2026754
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License Number State | IL
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