Provider Demographics
NPI:1780638353
Name:LAVA SUPPLY, INC.
Entity Type:Organization
Organization Name:LAVA SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:TURGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-329-1238
Mailing Address - Street 1:4011 AMALFI DR
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-5634
Mailing Address - Country:US
Mailing Address - Phone:847-329-1238
Mailing Address - Fax:847-329-1255
Practice Address - Street 1:7564 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-3335
Practice Address - Country:US
Practice Address - Phone:847-329-1238
Practice Address - Fax:847-329-1255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000377332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL348900572001Medicaid
IL4425630001Medicare ID - Type Unspecified