Provider Demographics
NPI:1538669510
Name:OA LABS CLINIC LLC.
Entity Type:Organization
Organization Name:OA LABS CLINIC LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MATARAGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-235-0220
Mailing Address - Street 1:6321 FAIRVIEW AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-2886
Mailing Address - Country:US
Mailing Address - Phone:630-235-0220
Mailing Address - Fax:985-370-2321
Practice Address - Street 1:6321 FAIRVIEW AVE STE B
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-2886
Practice Address - Country:US
Practice Address - Phone:630-235-0220
Practice Address - Fax:985-370-2321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336070137207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH63416Medicaid