Healthcare Provider Details

I. General information

NPI: 1124368030
Provider Name (Legal Business Name): CLAUDIA BALLESTEROS ASSOCIATES, BACHL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5631 S. RICHMOND
CHICAGO IL
60629
US

IV. Provider business mailing address

5631 S RICHMOND ST
CHICAGO IL
60629-2126
US

V. Phone/Fax

Practice location:
  • Phone: 773-546-8587
  • Fax:
Mailing address:
  • Phone: 773-546-8587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberB42310086649
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: