Healthcare Provider Details

I. General information

NPI: 1720881212
Provider Name (Legal Business Name): O2 FITNESS AND NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 03/31/2025
Certification Date: 03/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12609 S KROLL DR
ALSIP IL
60803-3221
US

IV. Provider business mailing address

4839 W 121ST PL
ALSIP IL
60803-2943
US

V. Phone/Fax

Practice location:
  • Phone: 708-969-6110
  • Fax:
Mailing address:
  • Phone: 708-819-2289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: PAOLA AMBROSE
Title or Position: OWNER, RDN, LDN
Credential: BA, RDN, LDN
Phone: 708-819-2289