Healthcare Provider Details

I. General information

NPI: 1346961224
Provider Name (Legal Business Name): KAYLA BURGOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3306 W 63RD ST
CHICAGO IL
60629-3317
US

IV. Provider business mailing address

7101 N CICERO AVE STE 202
LINCOLNWOOD IL
60712-2143
US

V. Phone/Fax

Practice location:
  • Phone: 773-433-6210
  • Fax: 866-744-0950
Mailing address:
  • Phone: 773-433-6210
  • Fax: 866-744-0950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: