# COMMUNITY NEUROLOGIC CENTER SC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1487852679
- **Authorized official:** MR. BORIS LAKE (BUSINESS MANAGER)
- **Authorized official phone:** (630) 208-7735

## Contact information

- **Practice address:** 2172 BLACKBERRY DR, SUITE 202, GENEVA, IL 60134-1073
- **Practice address phone:** (630) 208-7735
- **Practice address fax:** (630) 208-6956
- **Mailing address:** 2172 BLACKBERRY DR, SUITE 202, GENEVA, IL 60134-1073
- **Mailing address phone:** (630) 208-7735
- **Mailing address fax:** (630) 208-6956

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261Q00000X | Clinic/Center | 036-093008 | IL | Yes |

## Other

- **Enumeration date:** 07/10/2007
- **Last updated:** 09/11/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 036-093008 | MEDICAL LICENSE | IL |
| 05 | — | 036093008 | — | IL |