Healthcare Provider Details

I. General information

NPI: 1124643234
Provider Name (Legal Business Name): IMAGINE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 W GRAND AVE
CHICAGO IL
60654
US

IV. Provider business mailing address

710 W GRAND AVE
CHICAGO IL
60654-5566
US

V. Phone/Fax

Practice location:
  • Phone: 312-300-2190
  • Fax:
Mailing address:
  • Phone: 312-300-2190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RACHEL NORRIS
Title or Position: OWNER
Credential: MD
Phone: 412-606-6810