Healthcare Provider Details

I. General information

NPI: 1376290866
Provider Name (Legal Business Name): MVP RESTORATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 MERCHANDISE MART PLZ STE 1225
CHICAGO IL
60654-4357
US

IV. Provider business mailing address

222 MERCHANDISE MART PLZ STE 1225
CHICAGO IL
60654-4357
US

V. Phone/Fax

Practice location:
  • Phone: 949-878-6542
  • Fax:
Mailing address:
  • Phone: 949-878-6542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: SHEM HAKOLA
Title or Position: CEO
Credential:
Phone: 949-878-6542