Healthcare Provider Details

I. General information

NPI: 1891123832
Provider Name (Legal Business Name): BELOVED COMMUNITY FAMILY WELLNESS CTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2013
Last Update Date: 10/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6821 S HALSTED ST
CHICAGO IL
60621-1833
US

IV. Provider business mailing address

6821 S HALSTED STREET
CHICAGO IL
60621
US

V. Phone/Fax

Practice location:
  • Phone: 773-651-3629
  • Fax: 773-322-1599
Mailing address:
  • Phone: 773-651-3629
  • Fax: 773-322-1599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number86034476
License Number StateIL

VIII. Authorized Official

Name: MS. ASSENATH NAAMAN
Title or Position: DIETICIAN
Credential: LDN
Phone: 773-651-3629