Provider Demographics
NPI:1083103485
Name:LICE CLINICS OF AMERICA- NORTHWEST INDIANA
Entity Type:Organization
Organization Name:LICE CLINICS OF AMERICA- NORTHWEST INDIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KLACKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-624-4544
Mailing Address - Street 1:18909 PARRISH AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-9618
Mailing Address - Country:US
Mailing Address - Phone:630-624-4544
Mailing Address - Fax:
Practice Address - Street 1:1010 BREUCKMAN DR
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7530
Practice Address - Country:US
Practice Address - Phone:219-779-2289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty