Provider Demographics
NPI:1508222415
Name:DESURO ASSOCIATES LLC
Entity Type:Organization
Organization Name:DESURO ASSOCIATES LLC
Other - Org Name:IMAGES BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-685-3010
Mailing Address - Street 1:338 ALANA DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1784
Mailing Address - Country:US
Mailing Address - Phone:815-717-6207
Mailing Address - Fax:
Practice Address - Street 1:338 ALANA DR
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1784
Practice Address - Country:US
Practice Address - Phone:815-717-6207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04697-91648335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier