Healthcare Provider Details

I. General information

NPI: 1326641986
Provider Name (Legal Business Name): BROADLEAF HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 11/03/2024
Certification Date: 11/03/2024
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: 773-439-2552
Mailing address:
  • Phone: 773-947-4607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: MARIA ESPEJO
Title or Position: OWNER
Credential:
Phone: 773-947-4607