Provider Demographics
NPI:1659373900
Name:CHICAGO CLINICAL LABORATORIES, LTD
Entity Type:Organization
Organization Name:CHICAGO CLINICAL LABORATORIES, LTD
Other - Org Name:NICL LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WELDER
Authorized Official - Suffix:
Authorized Official - Credentials:MT (ASCP)
Authorized Official - Phone:847-509-9779
Mailing Address - Street 1:306 ERA DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1834
Mailing Address - Country:US
Mailing Address - Phone:847-509-9779
Mailing Address - Fax:847-509-9255
Practice Address - Street 1:306 ERA DR
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1834
Practice Address - Country:US
Practice Address - Phone:847-509-9779
Practice Address - Fax:847-509-9255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid