Provider Demographics
NPI:1912445800
Name:ALLURE SKIN AND LASER
Entity Type:Organization
Organization Name:ALLURE SKIN AND LASER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRAH
Authorized Official - Middle Name:KOPPIE
Authorized Official - Last Name:GAVRILOS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:2248-058-7113
Mailing Address - Street 1:832 ROSEMARY TER
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015
Mailing Address - Country:US
Mailing Address - Phone:224-805-8713
Mailing Address - Fax:
Practice Address - Street 1:240 E LAKE STREET
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101
Practice Address - Country:US
Practice Address - Phone:630-818-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015215363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty