=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821526328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABC LABS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2017
-----------------------------------------------------
Last Update Date | 05/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6449 S PULASKI RD STE 108
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60629-5148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-306-1259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6449 S PULASKI RD STE 108
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60629-5148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHAHIDA REHMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-289-6328
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 14D2118590
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------