Provider Demographics
NPI:1194854885
Name:MEDICAL INSTRUMENTATION CORP
Entity Type:Organization
Organization Name:MEDICAL INSTRUMENTATION CORP
Other - Org Name:COAGULATION CONSULTANTS LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-954-1134
Mailing Address - Street 1:1640 ELK BLVD
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-4722
Mailing Address - Country:US
Mailing Address - Phone:847-954-1134
Mailing Address - Fax:847-954-1136
Practice Address - Street 1:1640 ELK BLVD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4722
Practice Address - Country:US
Practice Address - Phone:847-954-1134
Practice Address - Fax:847-954-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D0413340291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D0413340OtherCLIA