Healthcare Provider Details

I. General information

NPI: 1104425552
Provider Name (Legal Business Name): FIFTH STAR COLLECTIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2020
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 N LAWNDALE AVE UNIT 2
CHICAGO IL
60647-1127
US

IV. Provider business mailing address

3914 W ALTGELD ST # 2E
CHICAGO IL
60647-1004
US

V. Phone/Fax

Practice location:
  • Phone: 720-982-9038
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. CONNOR WILLIAMS
Title or Position: CO-FOUNDER, SENIOR CONSULTANT
Credential:
Phone: 720-982-9038