Provider Demographics
NPI:1497419261
Name:DEFINED LJ, INC
Entity Type:Organization
Organization Name:DEFINED LJ, INC
Other - Org Name:DEFINED LJ, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNNERLYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-730-7374
Mailing Address - Street 1:2623 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1524
Mailing Address - Country:US
Mailing Address - Phone:123-722-6977
Mailing Address - Fax:
Practice Address - Street 1:2623 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1524
Practice Address - Country:US
Practice Address - Phone:312-722-6977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-27
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty