Healthcare Provider Details

I. General information

NPI: 1912652645
Provider Name (Legal Business Name): VODICKA FAMILY HEALTH & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13045 RAVINE DR
LEMONT IL
60439-7331
US

IV. Provider business mailing address

13045 RAVINE DR
LEMONT IL
60439-7331
US

V. Phone/Fax

Practice location:
  • Phone: 847-703-0262
  • Fax:
Mailing address:
  • Phone: 847-703-0262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: JESSICA VODICKA
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 847-703-0262