Healthcare Provider Details

I. General information

NPI: 1538534359
Provider Name (Legal Business Name): BODHI & SAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2015
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E 53RD ST STE 808
CHICAGO IL
60615-4583
US

IV. Provider business mailing address

1525 E 53RD ST STE 808
CHICAGO IL
60615-4583
US

V. Phone/Fax

Practice location:
  • Phone: 312-403-1853
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number070013559
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. ROGER FONG
Title or Position: MEMBER
Credential: MPT, LAC
Phone: 312-403-1853