Healthcare Provider Details

I. General information

NPI: 1689336760
Provider Name (Legal Business Name): PURE BODYWORKS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4107 W BELMONT AVE
CHICAGO IL
60641-4617
US

IV. Provider business mailing address

4107 W BELMONT AVE
CHICAGO IL
60641-4617
US

V. Phone/Fax

Practice location:
  • Phone: 773-710-9457
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number
License Number State

VIII. Authorized Official

Name: DR. GLADYS LARA
Title or Position: DOCTOR
Credential: DN
Phone: 773-710-9457