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General NPI Number Information
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NPI Number | 1922283373
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Entity Type | Organization
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Legal Business Name | COMMUNITY NEUROLOGIC CENTER SC
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Dates
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Enumeration Date | 01/04/2008
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Last Update Date | 04/02/2008
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Provider Practice Location Address
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Address Line | 2172 BLACKBERRY DRIVE SUITE 202
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City | GENEVA
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State | IL
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Zip | 60134-2577
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Country | US
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Telephone | 630-208-7735
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Fax | 630-208-6956
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Provider Business Mailing Address
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Address Line | 2172 BLACKBERRY DRIVE SUITE 202
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City | GENEVA
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State | IL
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Zip | 60134-2577
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Country | US
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Telephone | 630-208-7735
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Fax | 630-208-6956
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MR. BORIS LAKE
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Credential |
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Telephone | 630-208-7735
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 203.000950
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License Number State | IL
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