Provider Demographics
NPI:1760750665
Name:LONG TERM CARE LABORATORY, LLC.
Entity Type:Organization
Organization Name:LONG TERM CARE LABORATORY, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-422-7802
Mailing Address - Street 1:2458 ELMHURST RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-6311
Mailing Address - Country:US
Mailing Address - Phone:630-422-7800
Mailing Address - Fax:630-422-1360
Practice Address - Street 1:2458 ELMHURST RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-6311
Practice Address - Country:US
Practice Address - Phone:630-422-7800
Practice Address - Fax:630-422-1360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-06
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D2026754291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D2026754OtherCLIA
IL=========001Medicaid
IL=========001Medicaid