Healthcare Provider Details

I. General information

NPI: 1104857341
Provider Name (Legal Business Name): ABRAHAM'S MARK COMPREHENSIVE WELLNESS CENTER, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 S DORCHESTER AVE STE 100
CHICAGO IL
60628-1700
US

IV. Provider business mailing address

PO BOX 13677
BELFAST ME
04915-4027
US

V. Phone/Fax

Practice location:
  • Phone: 773-667-0768
  • Fax: 773-667-5529
Mailing address:
  • Phone: 773-667-0768
  • Fax: 773-667-5529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number036096686
License Number StateIL

VIII. Authorized Official

Name: DR. NICOLE D. KING
Title or Position: OWNER
Credential: MD
Phone: 773-667-0768