Healthcare Provider Details

I. General information

NPI: 1588494264
Provider Name (Legal Business Name): YUVODKA SHARICE LITTLE PARAMEDICAL ARTIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4821 W 103RD ST
OAK LAWN IL
60453-3955
US

IV. Provider business mailing address

1001 E 153RD ST
SOUTH HOLLAND IL
60473-1104
US

V. Phone/Fax

Practice location:
  • Phone: 800-780-2959
  • Fax: 800-918-3011
Mailing address:
  • Phone: 708-770-3555
  • Fax: 800-918-3011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number230343
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: