Healthcare Provider Details

I. General information

NPI: 1386144665
Provider Name (Legal Business Name): BLUE ISLAND TRADITIONAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1843 S RACINE AVE
CHICAGO IL
60608-3213
US

IV. Provider business mailing address

1843 S RACINE AVE
CHICAGO IL
60608-3213
US

V. Phone/Fax

Practice location:
  • Phone: 773-332-9438
  • Fax:
Mailing address:
  • Phone: 773-332-9438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1980011282
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227014734
License Number StateIL

VIII. Authorized Official

Name: BEATRICE SCESCKE
Title or Position: OWNER
Credential:
Phone: 312-291-8298