Organization
FAIRBANKS, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISA CARNES (PRINCIPAL)
(312) 450-6382
Entity
Organization
Contact information
Practice address
3880 SALEM LAKE DR STE A, LONG GROVE, IL 60047-5292
(312) 321-1225
Mailing address
3880 SALEM LAKE DR STE A, LONG GROVE, IL 60047-5292
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
208449
—
AL
Enumeration date
02/07/2018
Last updated
02/07/2018
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