Provider Demographics
NPI:1346530201
Name:IMPALA EXPRESS CLINICAL LABORATORY SERVICE INC
Entity Type:Organization
Organization Name:IMPALA EXPRESS CLINICAL LABORATORY SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEMAYEHU
Authorized Official - Middle Name:M
Authorized Official - Last Name:GEBRESELLASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-951-5168
Mailing Address - Street 1:845 N MICHIGAN AVE STE 944E
Mailing Address - Street 2:845 N. MICHIGAN AVE, SUITE # 944-E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2213
Mailing Address - Country:US
Mailing Address - Phone:312-202-0328
Mailing Address - Fax:312-202-0320
Practice Address - Street 1:845 N MICHIGAN AVE STE 944E
Practice Address - Street 2:845 N. MICHIGAN AVE, SUITE # 944-E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2213
Practice Address - Country:US
Practice Address - Phone:312-202-0328
Practice Address - Fax:312-202-0320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D2018991291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory