Provider Demographics
NPI:1295136794
Name:VIRU SC
Entity type:Organization
Organization Name:VIRU SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-423-6178
Mailing Address - Street 1:2901 N CLYBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-8101
Mailing Address - Country:US
Mailing Address - Phone:773-384-7977
Mailing Address - Fax:773-451-8285
Practice Address - Street 1:2901 N CLYBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-8101
Practice Address - Country:US
Practice Address - Phone:773-384-7977
Practice Address - Fax:773-451-8285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier