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General NPI Number Information
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NPI Number | 1811656028
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Entity Type | Individual
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Provider Name | SHAHREQ ALI KHAN BACHELOR OF SCIENCE
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Gender | Male
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Dates
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Enumeration Date | 12/15/2021
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Last Update Date | 02/08/2022
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Provider Practice Location Address
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Address Line | 3949 GROVE AVE
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City | GURNEE
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State | IL
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Zip | 60031-2118
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Country | US
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Telephone | 224-202-7777
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Fax |
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Provider Business Mailing Address
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Address Line | 3949 GROVE AVE
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City | GURNEE
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State | IL
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Zip | 60031-2118
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Country | US
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Telephone | 224-202-7777
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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 | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 14D2250825
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License Number State | IL
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