Healthcare Provider Details

I. General information

NPI: 1891574927
Provider Name (Legal Business Name): CORALIS HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2023
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 WALKER AVE STE B
CLARENDON HILLS IL
60514-1351
US

IV. Provider business mailing address

47 W DIVISION ST STE 360
CHICAGO IL
60610-2419
US

V. Phone/Fax

Practice location:
  • Phone: 708-722-6218
  • Fax:
Mailing address:
  • Phone: 708-722-6061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGELICA ROBLES
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 980-890-8668