Provider Demographics
NPI:1548514482
Name:MENS HEALTH LASALLE LLC
Entity type:Organization
Organization Name:MENS HEALTH LASALLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MIGLORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-229-1986
Mailing Address - Street 1:7611 PRESLAR CT
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-5321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 S. LASALLE
Practice Address - Street 2:SUITE 1130
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603
Practice Address - Country:US
Practice Address - Phone:480-229-1986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008745363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty