Provider Demographics
NPI:1457711269
Name:LAKE COUNTY VEIN SPECIALISTS, SC
Entity Type:Organization
Organization Name:LAKE COUNTY VEIN SPECIALISTS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-928-5234
Mailing Address - Street 1:1425 N HUNT CLUB RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-2632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1425 N HUNT CLUB RD
Practice Address - Street 2:SUITE 202
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2632
Practice Address - Country:US
Practice Address - Phone:630-928-5234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty