Provider Demographics
NPI:1356395396
Name:LIFECORE SC
Entity type:Organization
Organization Name:LIFECORE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:BEADLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-243-0145
Mailing Address - Street 1:14234 S BELL RD
Mailing Address - Street 2:#137
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8122
Mailing Address - Country:US
Mailing Address - Phone:630-243-0145
Mailing Address - Fax:630-257-0854
Practice Address - Street 1:106 STEPHEN ST
Practice Address - Street 2:LL4
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-3674
Practice Address - Country:US
Practice Address - Phone:630-243-0145
Practice Address - Fax:630-257-0854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty