Healthcare Provider Details

I. General information

NPI: 1417618380
Provider Name (Legal Business Name): GARLAND LEGACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 SOUTH BLVD
OAK PARK IL
60302-2823
US

IV. Provider business mailing address

1033 SOUTH BLVD
OAK PARK IL
60302-2823
US

V. Phone/Fax

Practice location:
  • Phone: 708-965-0667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MAYA GARLAND
Title or Position: DIRECTOR
Credential:
Phone: 708-925-7672