Healthcare Provider Details

I. General information

NPI: 1346515244
Provider Name (Legal Business Name): VITA NOBLESSE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6006 W. 159TH ST BLDG A, STE 2B/WEST
OAK FOREST IL
60452-2904
US

IV. Provider business mailing address

6006 W. 159TH ST BLDG A, STE 2B/WEST
OAK FOREST IL
60452-2904
US

V. Phone/Fax

Practice location:
  • Phone: 708-941-1174
  • Fax:
Mailing address:
  • Phone: 708-941-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number036.126980
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number036.126980
License Number StateIL

VIII. Authorized Official

Name: D'LOREYN WALKER
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 708-941-1174