Provider Demographics
NPI:1407023849
Name:SOUTH LAKE MEDICAL SERVICES, LTD
Entity Type:Organization
Organization Name:SOUTH LAKE MEDICAL SERVICES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:THACHENKERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-375-1900
Mailing Address - Street 1:2621 E 75TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-3705
Mailing Address - Country:US
Mailing Address - Phone:773-375-1900
Mailing Address - Fax:773-375-8279
Practice Address - Street 1:2621 E 75TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3705
Practice Address - Country:US
Practice Address - Phone:773-375-1900
Practice Address - Fax:773-375-8279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036049708261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care