MEDICARE: LAK IMAGING 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	2471S1302X	Sonography Radiologic Technologist	RDMS 95906

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01632794	OTHER	IL	BCBS RADIOLOGY ULTRASOUND

General Provider Information

NPI Number	:	1821023391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAK IMAGING INC

Provider Business Mailing Address
First Line	:	1829 N CLEVELAND AVE
Second Line	:	UNIT C
City	:	CHICAGO
State	:	IL
Zip	:	60614-5273
Country	:	US
Telephone Number	:	312-482-8730
Fax Number	:	773-935-8087

Provider Business Practice Location Address
First Line	:	1829 N CLEVELAND AVE
Second Line	:	UNIT C
City	:	CHICAGO
State	:	IL
Zip	:	60614-5273
Country	:	US
Telephone Number	:	312-482-8730
Fax Number	:	773-935-8087

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LARISSA KOULIEV
Credential	:	RDMS
Telephone Number	:	312-482-8730

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	08/22/2020

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Directions to “LAK IMAGING INC ” Practice Location

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