Healthcare Provider Details

I. General information

NPI: 1023953148
Provider Name (Legal Business Name): SACRED OPAL ACUPUNCTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 WOODSIDE LN
GLENDALE HEIGHTS IL
60139-2128
US

IV. Provider business mailing address

1903 WOODSIDE LN
GLENDALE HEIGHTS IL
60139-2128
US

V. Phone/Fax

Practice location:
  • Phone: 630-886-3481
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: ALEX LEISER
Title or Position: OWNER
Credential: LAC
Phone: 630-886-3481