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General NPI Number Information
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NPI Number | 1811658024
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Entity Type | Organization
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Legal Business Name | ILLINIOS TECH LAB INC
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Dates
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Enumeration Date | 01/10/2022
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Last Update Date | 03/29/2022
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Provider Practice Location Address
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Address Line | 1818 SKOKIE BLVD
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City | NORTHBROOK
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State | IL
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Zip | 60062-4106
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Country | US
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Telephone | 312-952-3034
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Fax |
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Provider Business Mailing Address
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Address Line | 8244 CENTRAL PARK AVE
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City | SKOKIE
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State | IL
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Zip | 60076-2909
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Country | US
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Telephone | 312-952-3034
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | SHAFEEQ UDDIN KHAJA
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Credential |
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Telephone | 312-952-3034
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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 |
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License Number State |
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