Provider Demographics
NPI:1225254113
Name:ADEONA CLINICAL LABORATORY LLC
Entity Type:Organization
Organization Name:ADEONA CLINICAL LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NARAYAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:TORKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-378-2100
Mailing Address - Street 1:391 QUADRANGLE DR
Mailing Address - Street 2:SUITE N9
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-3442
Mailing Address - Country:US
Mailing Address - Phone:630-378-2100
Mailing Address - Fax:630-378-2990
Practice Address - Street 1:391 QUADRANGLE DR
Practice Address - Street 2:SUITE N8
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3442
Practice Address - Country:US
Practice Address - Phone:630-378-2100
Practice Address - Fax:630-378-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILD1587714291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL213625Medicare ID - Type Unspecified