Organization
COMMUNITY NEUROLOGIC CENTER SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BORIS LAKE (BUSINESS MANAGER)
(630) 208-7735
Entity
Organization
Contact information
Practice address
2172 BLACKBERRY DR, SUITE 202, GENEVA, IL 60134-1073
(630) 208-7735
(630) 208-6956
Mailing address
2172 BLACKBERRY DR, SUITE 202, GENEVA, IL 60134-1073
(630) 208-7735
(630) 208-6956
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
036-093008
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036-093008
MEDICAL LICENSE
IL
05
—
036093008
—
IL
Enumeration date
07/10/2007
Last updated
09/11/2012
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