Healthcare Provider Details

I. General information

NPI: 1134650484
Provider Name (Legal Business Name): DISENTANGLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 S KEDZIE AVE
CHICAGO IL
60655-2330
US

IV. Provider business mailing address

11104 S KEDZIE AVE
CHICAGO IL
60655-2330
US

V. Phone/Fax

Practice location:
  • Phone: 708-581-6487
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name: JACLYN O'CONNELL
Title or Position: OWNER
Credential:
Phone: 708-581-6487