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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