Provider Demographics
NPI:1720452709
Name:HANSEN, DONALD (OWNER)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 SPRUCE RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2504
Mailing Address - Country:US
Mailing Address - Phone:630-750-7378
Mailing Address - Fax:630-929-8057
Practice Address - Street 1:541 SPRUCE RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2504
Practice Address - Country:US
Practice Address - Phone:630-750-7378
Practice Address - Fax:630-929-8057
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D2099042291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory