Healthcare Provider Details

I. General information

NPI: 1922594613
Provider Name (Legal Business Name): NORTHWEST ADULT WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 W 95TH SUITE 3
CHICAGO IL
60628
US

IV. Provider business mailing address

5352 N LINCOLN AVE
CHICAGO IL
60625-2316
US

V. Phone/Fax

Practice location:
  • Phone: 773-468-2110
  • Fax:
Mailing address:
  • Phone: 773-353-5047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMAD KHAMIS
Title or Position: PRESIDENT
Credential: MD
Phone: 773-468-2110