Provider Demographics
NPI:1487852679
Name:COMMUNITY NEUROLOGIC CENTER SC
Entity Type:Organization
Organization Name:COMMUNITY NEUROLOGIC CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-208-7735
Mailing Address - Street 1:2172 BLACKBERRY DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-1073
Mailing Address - Country:US
Mailing Address - Phone:630-208-7735
Mailing Address - Fax:630-208-6956
Practice Address - Street 1:2172 BLACKBERRY DR
Practice Address - Street 2:SUITE 202
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-1073
Practice Address - Country:US
Practice Address - Phone:630-208-7735
Practice Address - Fax:630-208-6956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-093008261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-093008OtherMEDICAL LICENSE
IL036093008Medicaid
IL211306Medicare PIN