Healthcare Provider Details

I. General information

NPI: 1205345337
Provider Name (Legal Business Name): GLOW HEALTH AND WELLNESS MEDICAL SPA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 W MONROE ST STE 100
CHICAGO IL
60607-2460
US

IV. Provider business mailing address

1001 W 15TH ST UNIT 320
CHICAGO IL
60608-2778
US

V. Phone/Fax

Practice location:
  • Phone: 630-901-2879
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number209008594
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number209008594
License Number StateIL

VIII. Authorized Official

Name: MS. TAJUANA D. JOHNSON
Title or Position: OWNER, MANAGER
Credential: FNP
Phone: 630-901-2879