Provider Demographics
NPI:1750635868
Name:CHICAGO CENTER FOR ANTI AGING INC
Entity Type:Organization
Organization Name:CHICAGO CENTER FOR ANTI AGING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SPERON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-952-1412
Mailing Address - Street 1:950 N NORTHWEST HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-2349
Mailing Address - Country:US
Mailing Address - Phone:630-952-1412
Mailing Address - Fax:630-952-1447
Practice Address - Street 1:950 N NORTHWEST HWY STE 102
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-2349
Practice Address - Country:US
Practice Address - Phone:630-952-1412
Practice Address - Fax:630-952-1447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty