Healthcare Provider Details

I. General information

NPI: 1710828769
Provider Name (Legal Business Name): CARLY IACULLO
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W MADISON ST STE 2
CHICAGO IL
60607-2055
US

IV. Provider business mailing address

121 W CHESTNUT ST APT 1308
CHICAGO IL
60610-3155
US

V. Phone/Fax

Practice location:
  • Phone: 773-234-1042
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198.011985
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: