Provider Demographics
NPI:1740315332
Name:SURGIACL ASSISTINGSERVICES OF LAKE COUNTY
Entity type:Organization
Organization Name:SURGIACL ASSISTINGSERVICES OF LAKE COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGICAL ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:LADELL
Authorized Official - Last Name:LUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1224-399-9317
Mailing Address - Street 1:2400 N SAMSON WAY
Mailing Address - Street 2:APT#2D
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60087-5079
Mailing Address - Country:US
Mailing Address - Phone:122-439-9931
Mailing Address - Fax:224-944-0084
Practice Address - Street 1:2400 N SAMSON WAY
Practice Address - Street 2:APT#2D
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60087-5079
Practice Address - Country:US
Practice Address - Phone:122-439-9931
Practice Address - Fax:224-944-0084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Single Specialty