Healthcare Provider Details

I. General information

NPI: 1144593369
Provider Name (Legal Business Name): SOUTH LOOP ENDOSCOPY AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2012
Last Update Date: 02/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2334 S WABASH AVE
CHICAGO IL
60616-2112
US

IV. Provider business mailing address

1S280 SUMMIT AVE COURT A
OAKBROOK TERRACE IL
60181-3984
US

V. Phone/Fax

Practice location:
  • Phone: 630-889-9889
  • Fax: 630-889-8977
Mailing address:
  • Phone: 630-889-9889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID C CHUA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 630-889-9889