Healthcare Provider Details

I. General information

NPI: 1306439591
Provider Name (Legal Business Name): IVAN ZAVALA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 W CERMAK RD
CHICAGO IL
60616-1913
US

IV. Provider business mailing address

2545 S HILLOCK AVE
CHICAGO IL
60608-5736
US

V. Phone/Fax

Practice location:
  • Phone: 312-889-1239
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198.001469
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: