Basic Information
| Provider Information | |||||||||
| NPI: | 1508134800 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE COUNTY HEALTH DEPARTMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3002 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3002 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2011 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | CERK | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8473778200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | 178.004336 | IL | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.