Provider Demographics
NPI:1871308999
Name:LAKE FOREST REGENESIS MEDICAL CENTER, PLLC
Entity type:Organization
Organization Name:LAKE FOREST REGENESIS MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-C
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALLANA
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:224-436-8006
Mailing Address - Street 1:1025 W EVERETT RD STE 2
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-2668
Mailing Address - Country:US
Mailing Address - Phone:224-436-8006
Mailing Address - Fax:949-703-8371
Practice Address - Street 1:1025 W EVERETT RD STE 2
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-2668
Practice Address - Country:US
Practice Address - Phone:224-436-8006
Practice Address - Fax:949-703-8371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center