Healthcare Provider Details

I. General information

NPI: 1336414473
Provider Name (Legal Business Name): HEALTHY HABITS KEY TO WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2971 W ALGONQUIN RD STE 103
ALGONQUIN IL
60102-9406
US

IV. Provider business mailing address

2971 W ALGONQUIN RD STE 103
ALGONQUIN IL
60102-9406
US

V. Phone/Fax

Practice location:
  • Phone: 815-704-5433
  • Fax: 847-669-1228
Mailing address:
  • Phone: 847-458-1879
  • Fax: 847-458-2079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number036.037547
License Number StateIL

VIII. Authorized Official

Name: KARIN BOODE
Title or Position: PARTNER
Credential:
Phone: 847-458-1879