MEDICARE: NORTH CHICAGO LICE CLINIC INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician

General Provider Information

NPI Number	:	1205302965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH CHICAGO LICE CLINIC INC

Provider Business Mailing Address
First Line	:	6308 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-3711
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6308 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-3711
Country	:	US
Telephone Number	:	773-430-5679
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SAMI IMSAIH
Credential	:
Telephone Number	:	773-620-7961

Provider Enumeration Date	:	10/22/2018
Last Update Date	:	10/22/2018

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