Provider Demographics
NPI:1356344378
Name:LIFESCAN CHICAGO LLC
Entity type:Organization
Organization Name:LIFESCAN CHICAGO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-452-6842
Mailing Address - Street 1:2242 W HARRISON ST
Mailing Address - Street 2:STE 100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3515
Mailing Address - Country:US
Mailing Address - Phone:312-243-3200
Mailing Address - Fax:312-243-5759
Practice Address - Street 1:2242 W HARRISON ST
Practice Address - Street 2:STE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3515
Practice Address - Country:US
Practice Address - Phone:312-243-3200
Practice Address - Fax:312-243-5759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid