Organization
GLEN RIDGE IMAGING LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GLEN JOHN NISIVOCCIA D C (PRESIDENT)
(708) 478-3000
Entity
Organization
Contact information
Practice address
19602 S LAGRANGE ROAD, MOKENA, IL 60448-9321
(708) 478-3000
(708) 478-3007
Mailing address
19602 S LAGRANGE ROAD, MOKENA, IL 60448-9321
(708) 478-3000
(708) 478-3007
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
—
IL
Other
Enumeration date
10/04/2006
Last updated
08/22/2020
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