Provider Demographics
NPI:1679165039
Name:SOUTH CHICAGO LAB LIMITED
Entity Type:Organization
Organization Name:SOUTH CHICAGO LAB LIMITED
Other - Org Name:SOUTH CHICAGO LAB LIMITED
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:KARTHIK
Authorized Official - Middle Name:V
Authorized Official - Last Name:ACHARI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:630-991-8787
Mailing Address - Street 1:10500 SOUTHWEST HWY STE C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2805
Mailing Address - Country:US
Mailing Address - Phone:630-991-8787
Mailing Address - Fax:
Practice Address - Street 1:10500 SOUTHWEST HWY STE C
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2805
Practice Address - Country:US
Practice Address - Phone:815-440-9285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-08
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILNAMedicaid