Healthcare Provider Details

I. General information

NPI: 1013452168
Provider Name (Legal Business Name): PROSALUD6238 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6238 CERMAK RD
BERWYN IL
60402-2319
US

IV. Provider business mailing address

6238 CERMAK RD
BERWYN IL
60402-2319
US

V. Phone/Fax

Practice location:
  • Phone: 708-795-5020
  • Fax: 708-795-5158
Mailing address:
  • Phone: 708-795-5020
  • Fax: 708-795-5158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036084800
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036085902
License Number StateIL

VIII. Authorized Official

Name: DR. ELIZABETH CANELAS
Title or Position: MD
Credential:
Phone: 708-829-7422