Provider Demographics
NPI:1316496359
Name:GRUMBINE, SUSAN JACQUELINE (LAC)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JACQUELINE
Last Name:GRUMBINE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18330 RIEGEL RD
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-3431
Mailing Address - Country:US
Mailing Address - Phone:708-612-4421
Mailing Address - Fax:
Practice Address - Street 1:575 W EXCHANGE ST
Practice Address - Street 2:STE 104
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-2003
Practice Address - Country:US
Practice Address - Phone:708-612-4421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001283171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist