Healthcare Provider Details

I. General information

NPI: 1730823162
Provider Name (Legal Business Name): PEARLS OF VEDA MEDICAL AND HOLISTIC SPA. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 07/21/2024
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 W 95TH ST
CHICAGO IL
60628-1155
US

IV. Provider business mailing address

22615 HUNTERS TRL
FRANKFORT IL
60423-6001
US

V. Phone/Fax

Practice location:
  • Phone: 708-879-3043
  • Fax: 855-640-4865
Mailing address:
  • Phone: 773-981-8609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AVIDA NUBIA BUSSELL
Title or Position: BUSINESS OWNER/MEDICAL DIRECTOR
Credential: MD
Phone: 708-586-9798