1225329295 NPI number — ERBS ORGANIC WELLNESS CENTER

Table of content: (NPI 1225329295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225329295 NPI number — ERBS ORGANIC WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERBS ORGANIC WELLNESS CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225329295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6420 W 127TH ST
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
PALOS HEIGHTS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60463-2269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-629-0708
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7519 175TH ST
Provider Second Line Business Practice Location Address:
UNIT 1E
Provider Business Practice Location Address City Name:
TINLEY PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60477-6929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-466-1085
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ERBS
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DR
Authorized Official Telephone Number:
708-629-0708

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038.011637 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 038.011637 . This is a "STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".