Provider Demographics
NPI:1821318643
Name:EPIC SURGICAL SOLUTION COMPANY
Entity Type:Organization
Organization Name:EPIC SURGICAL SOLUTION COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED SURGICAL ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:LARAY
Authorized Official - Last Name:VINSON
Authorized Official - Suffix:
Authorized Official - Credentials:RSA
Authorized Official - Phone:931-215-1574
Mailing Address - Street 1:P.O. BOX 1416
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440
Mailing Address - Country:US
Mailing Address - Phone:931-215-1574
Mailing Address - Fax:866-535-5342
Practice Address - Street 1:5885 FOREST VIEW RD
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-2900
Practice Address - Country:US
Practice Address - Phone:931-215-1574
Practice Address - Fax:866-535-5342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000232171W00000X
IL238000042171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1881775880OtherNPI
IL1235360959OtherNPI