Provider Demographics
NPI:1972784429
Name:WEST TOWN MEDICAL ASSOCIATES,SC
Entity Type:Organization
Organization Name:WEST TOWN MEDICAL ASSOCIATES,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:
Authorized Official - Last Name:LARA VALLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-829-4636
Mailing Address - Street 1:3 NORRIS DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5124
Mailing Address - Country:US
Mailing Address - Phone:630-655-0544
Mailing Address - Fax:
Practice Address - Street 1:1859 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-5513
Practice Address - Country:US
Practice Address - Phone:312-829-4636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207KA0200X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty