Provider Demographics
NPI:1508912262
Name:WAUKEGAN ILLINOIS HOSPITAL COMPANY LLC
Entity Type:Organization
Organization Name:WAUKEGAN ILLINOIS HOSPITAL COMPANY LLC
Other - Org Name:VISTA SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, BUSINESS SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7466
Mailing Address - Street 1:1050 RED OAK LN
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-4998
Mailing Address - Country:US
Mailing Address - Phone:847-360-3000
Mailing Address - Fax:
Practice Address - Street 1:1050 RED OAK LN
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-4998
Practice Address - Country:US
Practice Address - Phone:847-360-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAUKEGAN HOSPITAL COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-26
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213819Medicare PIN