Healthcare Provider Details

I. General information

NPI: 1053112631
Provider Name (Legal Business Name): MINDCORE INTEGRATIVE HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2025
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON ST
JOLIET IL
60435-8200
US

IV. Provider business mailing address

903 S BODIN ST
HINSDALE IL
60521-4383
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-7133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMEERA GUTTIKONDA
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 224-542-0736