Healthcare Provider Details

I. General information

NPI: 1518766187
Provider Name (Legal Business Name): MR. SALADIN FARD YACUB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 03/07/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W JACKSON BLVD
CHICAGO IL
60604-3589
US

IV. Provider business mailing address

8718 S CRANDON AVE
CHICAGO IL
60617-3025
US

V. Phone/Fax

Practice location:
  • Phone: 312-583-0061
  • Fax:
Mailing address:
  • Phone: 708-901-2180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.0204055
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: