Healthcare Provider Details

I. General information

NPI: 1215715529
Provider Name (Legal Business Name): EXQUISITE WELLNESS BAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 W POLK ST # 100-203
CHICAGO IL
60605-2000
US

IV. Provider business mailing address

5456 PEACHTREE BLVD # 121
ATLANTA GA
30341-2235
US

V. Phone/Fax

Practice location:
  • Phone: 312-852-3655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PRINCESS LOMAX
Title or Position: CEO
Credential:
Phone: 312-671-3800