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General NPI Number Information
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NPI Number | 1952791220
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Entity Type | Organization
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Legal Business Name | CHICAGO LIPO LASER, LLC
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Dates
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Enumeration Date | 01/26/2015
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Last Update Date | 01/26/2015
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Provider Practice Location Address
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Address Line | 5318 W DEVON AVE
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City | CHICAGO
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State | IL
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Zip | 60646-4108
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Country | US
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Telephone | 773-774-6440
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Fax |
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Provider Business Mailing Address
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Address Line | 5318 W DEVON AVE
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City | CHICAGO
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State | IL
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Zip | 60646-4108
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Country | US
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Telephone | 773-774-6440
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MR. GEORGE THOMAS NELLAMATTATHIL
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Credential |
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Telephone | 773-774-6440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS1200X
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Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
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License Number | IL1197
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License Number State | IL
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