Provider Demographics
NPI:1023337482
Name:CHRISTINA DOLACK LLC
Entity type:Organization
Organization Name:CHRISTINA DOLACK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DOLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-357-8511
Mailing Address - Street 1:271 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:IL
Mailing Address - Zip Code:61360-9323
Mailing Address - Country:US
Mailing Address - Phone:815-357-8511
Mailing Address - Fax:815-357-1238
Practice Address - Street 1:271 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:IL
Practice Address - Zip Code:61360-9323
Practice Address - Country:US
Practice Address - Phone:815-357-8511
Practice Address - Fax:815-357-1238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107487207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty