Provider Demographics
NPI:1043598501
Name:LIFE CLINIC, LLC
Entity Type:Organization
Organization Name:LIFE CLINIC, LLC
Other - Org Name:GENESIS MEDICAL, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-342-9033
Mailing Address - Street 1:2780 PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-6540
Mailing Address - Country:US
Mailing Address - Phone:847-342-9033
Mailing Address - Fax:
Practice Address - Street 1:20 E NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3223
Practice Address - Country:US
Practice Address - Phone:847-342-9033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-01
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-007948111N00000X
IL122300000X
IL0360520252084N0400X
208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty