Provider Demographics
NPI:1245772748
Name:OPTIMUM FAITH LAB CORP
Entity Type:Organization
Organization Name:OPTIMUM FAITH LAB CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:OPAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-610-0434
Mailing Address - Street 1:1360 N GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-1104
Mailing Address - Country:US
Mailing Address - Phone:224-610-0434
Mailing Address - Fax:855-325-1872
Practice Address - Street 1:1360 N GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-1104
Practice Address - Country:US
Practice Address - Phone:224-610-0434
Practice Address - Fax:855-325-1872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory