Provider Demographics
NPI:1447345830
Name:CENTRAL CLINICAL LABS, INC
Entity type:Organization
Organization Name:CENTRAL CLINICAL LABS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IMTIAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-788-1577
Mailing Address - Street 1:6858 W ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2341
Mailing Address - Country:US
Mailing Address - Phone:773-788-1577
Mailing Address - Fax:773-788-1579
Practice Address - Street 1:6858 W ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2341
Practice Address - Country:US
Practice Address - Phone:773-788-1577
Practice Address - Fax:773-788-1579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL586470Medicare ID - Type UnspecifiedPROVIDER NUMBER