Provider Demographics
NPI:1982745519
Name:GATHERING VALLEY CENTER
Entity Type:Organization
Organization Name:GATHERING VALLEY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGIY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIFSHITS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LAC
Authorized Official - Phone:847-568-0849
Mailing Address - Street 1:8019 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3611
Mailing Address - Country:US
Mailing Address - Phone:847-568-0849
Mailing Address - Fax:847-410-2123
Practice Address - Street 1:8019 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-3611
Practice Address - Country:US
Practice Address - Phone:847-568-0849
Practice Address - Fax:847-410-2123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198-000104261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center