Provider Demographics
NPI:1205052529
Name:TAVAKOLY, NASSER (RCSA)
Entity type:Individual
Prefix:MR
First Name:NASSER
Middle Name:
Last Name:TAVAKOLY
Suffix:
Gender:M
Credentials:RCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.BOX 9274
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60567-9274
Mailing Address - Country:US
Mailing Address - Phone:630-759-9070
Mailing Address - Fax:630-759-9067
Practice Address - Street 1:101 ROYCE RD.
Practice Address - Street 2:SUITE 5
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440
Practice Address - Country:US
Practice Address - Phone:630-759-9070
Practice Address - Fax:630-759-9067
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist