Healthcare Provider Details

I. General information

NPI: 1659778421
Provider Name (Legal Business Name): AWAKEN BLOSSOM FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2014
Last Update Date: 11/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6142 ROOSEVELT RD # 101
OAK PARK IL
60304-2311
US

IV. Provider business mailing address

6142 ROOSEVELT RD # 101
OAK PARK IL
60304-2311
US

V. Phone/Fax

Practice location:
  • Phone: 708-613-5690
  • Fax:
Mailing address:
  • Phone: 708-613-5690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198000100
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number227007446
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number227004827
License Number StateIL

VIII. Authorized Official

Name: MS. MILDRED ABONCE
Title or Position: VICE-PRESIDENT
Credential: LMT
Phone: 708-613-5690