Healthcare Provider Details

I. General information

NPI: 1063898591
Provider Name (Legal Business Name): MS. ISABEL FREGOSO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4956 W IRVING PARK RD SUITE 200
CHICAGO IL
60641-2640
US

IV. Provider business mailing address

4956 W IRVING PARK RD SUITE 200
CHICAGO IL
60641-2640
US

V. Phone/Fax

Practice location:
  • Phone: 773-725-5835
  • Fax: 773-725-5834
Mailing address:
  • Phone: 773-725-5835
  • Fax: 773-725-5834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number227.00318
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: