Healthcare Provider Details

I. General information

NPI: 1932700770
Provider Name (Legal Business Name): BROADLEAF HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3245 GROVE AVE STE 205
BERWYN IL
60402-3476
US

IV. Provider business mailing address

3245 GROVE AVE STE 205
BERWYN IL
60402-3476
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-4607
  • Fax:
Mailing address:
  • Phone: 773-947-4607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARIA ESPEJO
Title or Position: REHAB PRACTITIONER
Credential: OT/CCCPA
Phone: 773-947-4607