Healthcare Provider Details

I. General information

NPI: 1053712521
Provider Name (Legal Business Name): ESTELLA SPAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

486 S SPRING RD
ELMHURST IL
60126-3858
US

IV. Provider business mailing address

197 WEST ARMITAGE AVENUE
ELMHURST IL
60126
US

V. Phone/Fax

Practice location:
  • Phone: 630-834-8536
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number227002388
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: