Healthcare Provider Details

I. General information

NPI: 1437982931
Provider Name (Legal Business Name): MED SPA FOR ME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 SAINT CHARLES RD
BELLWOOD IL
60104-1133
US

IV. Provider business mailing address

4000 SAINT CHARLES RD
BELLWOOD IL
60104-1133
US

V. Phone/Fax

Practice location:
  • Phone: 707-267-4100
  • Fax:
Mailing address:
  • Phone: 707-267-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WU0100X
TaxonomyUrology Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MS. CARRIE JOHNSON
Title or Position: PRESIDENT
Credential: RN
Phone: 708-267-4100