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3004 Grand Ave Waukegan IL 60085-2321 | |
| (847) 377-8273 | |
| (847) 360-7377 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 3004 Grand Ave, Waukegan, Illinois |
| Authorized Official Name and Position | Angela Cooper (CFO) |
| Authorized Official Contact | 8473778000 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
3010 Grand Ave Waukegan IL 60085 Ph: (847) 377-8180 | 3004 Grand Ave Waukegan IL 60085-2321 Ph: (847) 377-8273 |
| NPI Number | 1720290091 |
|---|---|
| Provider Enumeration Date | 05/07/2007 |
| Last Update Date | 09/10/2024 |
| Certification Date | 09/10/2024 |
| Medicare PECOS PAC ID | 7214838861 |
|---|---|
| Medicare Enrollment ID | O20210621003037 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1720290091 | NPI | - | NPPES |
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