Healthcare Provider Details

I. General information

NPI: 1457937526
Provider Name (Legal Business Name): TAYONON E GBALA LMT,OMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 S AUSTIN BLVD APT 2S
OAK PARK IL
60304-2369
US

IV. Provider business mailing address

918 S AUSTIN BLVD APT 2S
OAK PARK IL
60304-2369
US

V. Phone/Fax

Practice location:
  • Phone: 708-205-2363
  • Fax:
Mailing address:
  • Phone: 708-205-2363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227003033
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: