Provider Demographics
NPI:1750506077
Name:NECK TO BACK LAKE COUNTY LLC
Entity type:Organization
Organization Name:NECK TO BACK LAKE COUNTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SERAFINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-283-0950
Mailing Address - Street 1:7177 CRIMSON RIDGE DR
Mailing Address - Street 2:SUITE 14
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6208
Mailing Address - Country:US
Mailing Address - Phone:815-227-9900
Mailing Address - Fax:815-227-9805
Practice Address - Street 1:71 WAUKEGAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-3009
Practice Address - Country:US
Practice Address - Phone:847-283-0950
Practice Address - Fax:847-283-0951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010204111N00000X
IL036104819207Q00000X
IL036-104819261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE62142Medicare UPIN