Provider Demographics
NPI:1588037873
Name:LCR PRIMARY CARE LLC
Entity Type:Organization
Organization Name:LCR PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:773-431-1508
Mailing Address - Street 1:9237 S PULASKI RD
Mailing Address - Street 2:STE 2S
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1454
Mailing Address - Country:US
Mailing Address - Phone:773-431-1508
Mailing Address - Fax:
Practice Address - Street 1:9237 S.PULASKI
Practice Address - Street 2:STE. 2S
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805
Practice Address - Country:US
Practice Address - Phone:773-431-1508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL302F00000X302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization