MEDICARE: GREENBAX HEALTH SOLUTIONS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1538792221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENBAX HEALTH SOLUTIONS, LLC

Provider Business Mailing Address
First Line	:	4922 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-3142
Country	:	US
Telephone Number	:	773-417-3784
Fax Number	:	773-417-3784

Provider Business Practice Location Address
First Line	:	4922 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-3142
Country	:	US
Telephone Number	:	312-285-7678
Fax Number	:

Authorized Official
Title or Position	:	CHIEF MEDICAL OFFICER
Name	:	DR. GREGORY C VACHON
Credential	:	MD
Telephone Number	:	312-285-7678

Provider Enumeration Date	:	02/20/2020
Last Update Date	:	09/23/2020

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