Basic Information
| Provider Information | |||||||||
| NPI: | 1205313020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ORTEGA | ||||||||
| FirstName: | LEILA | ||||||||
| MiddleName: | PEARL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RODRIGUEZ | ||||||||
| OtherFirstName: | LEILA | ||||||||
| OtherMiddleName: | PEARL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 409 PARKVIEW CT | ||||||||
| Address2: | |||||||||
| City: | ROUND LAKE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600733138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2244753824 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3002 GRAND AVE # ATP | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2018 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 041357635 | IL | Y | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No ID Information.