MEDICARE: LIL'S LOW CARB 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1467001396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIL'S LOW CARB INC

Provider Business Mailing Address
First Line	:	2738 W 111TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-1832
Country	:	US
Telephone Number	:	773-239-0355
Fax Number	:

Provider Business Practice Location Address
First Line	:	2738 W 111TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-1832
Country	:	US
Telephone Number	:	773-239-0355
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARCIE HARVEY
Credential	:
Telephone Number	:	773-239-0355

Provider Enumeration Date	:	09/04/2019
Last Update Date	:	09/04/2019

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