MEDICARE: LEILANI LABORATORY

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	291U00000X	Clinical Medical Laboratory		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1632963	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1912909961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEILANI LABORATORY

Provider Business Mailing Address
First Line	:	4320 W MONTROSE AVE
Second Line	:	STE C
City	:	CHICAGO
State	:	IL
Zip	:	60641-2016
Country	:	US
Telephone Number	:	773-283-0944
Fax Number	:	773-283-0882

Provider Business Practice Location Address
First Line	:	4320 W MONTROSE AVE
Second Line	:	STE C
City	:	CHICAGO
State	:	IL
Zip	:	60641-2016
Country	:	US
Telephone Number	:	773-283-0944
Fax Number	:	773-283-0882

Authorized Official
Title or Position	:	PRESIDENT
Name	:	FLORA M SAMPANG
Credential	:
Telephone Number	:	773-283-0944

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	08/22/2020

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