Healthcare Provider Details

I. General information

NPI: 1720581101
Provider Name (Legal Business Name): ARCH ANGEL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 S. RIVERSIDE PLAZA SUITE 875
CHICAGO IL
60606
US

IV. Provider business mailing address

10 S. RIVERSIDE PLAZA SUITE 875
CHICAGO IL
60606
US

V. Phone/Fax

Practice location:
  • Phone: 312-474-6189
  • Fax: 773-260-1479
Mailing address:
  • Phone: 312-474-6189
  • Fax: 773-260-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. ANTUAN DURALL WILBON
Title or Position: CEO/OWNER
Credential: M.S.W.
Phone: 312-474-6189