Healthcare Provider Details

I. General information

NPI: 1487407789
Provider Name (Legal Business Name): TULLIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2455 VICKI LN
NORTHBROOK IL
60062-6923
US

IV. Provider business mailing address

2455 VICKI LN
NORTHBROOK IL
60062-6923
US

V. Phone/Fax

Practice location:
  • Phone: 312-351-0988
  • Fax:
Mailing address:
  • Phone: 312-351-0988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KETKI MODI
Title or Position: PHYSICIAN
Credential:
Phone: 312-351-0988