Provider Demographics
NPI:1922292291
Name:NBHC NCTC INPR GREAT LAKES
Entity Type:Organization
Organization Name:NBHC NCTC INPR GREAT LAKES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPTOLLER
Authorized Official - Prefix:
Authorized Official - First Name:DUWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROZEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-688-2888
Mailing Address - Street 1:3001 6TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-2833
Mailing Address - Country:US
Mailing Address - Phone:847-688-4560
Mailing Address - Fax:
Practice Address - Street 1:3001 6TH ST STE A
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-2833
Practice Address - Country:US
Practice Address - Phone:847-688-4560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL HEALTH CLINIC GREAT LAKES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient