Organization
KATRINA LAKE MD LLC
Active
Organization
KATRINA LAKE MD LLC
Active
Other names
Live. Love. Wellness MD
Organization subpart
No
Provider details
NPI number
Authorized official
KATRINA LAKE MD (OWNER)
(708) 308-8974
Entity
Organization
Contact information
Practice address
18503 BELLAMY RD, COUNTRY CLUB HILLS, IL 60478-5279
(708) 365-8343
Mailing address
18503 BELLAMY RD, COUNTRY CLUB HILLS, IL 60478-5279
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036141229
—
IL
Enumeration date
04/14/2020
Last updated
05/01/2020
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