Provider Demographics
NPI:1992857833
Name:WOODLAKE TECHNOLOGIES INC
Entity Type:Organization
Organization Name:WOODLAKE TECHNOLOGIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-733-9800
Mailing Address - Street 1:666 W. HUBBARD ST.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5509
Mailing Address - Country:US
Mailing Address - Phone:312-733-9800
Mailing Address - Fax:312-243-9284
Practice Address - Street 1:666 W. HUBBARD ST
Practice Address - Street 2:SUITE 3
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-5509
Practice Address - Country:US
Practice Address - Phone:312-733-9800
Practice Address - Fax:312-243-9284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL28913027332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4839277Medicaid
MI4839277Medicaid
MI4839277Medicaid