Healthcare Provider Details

I. General information

NPI: 1487393880
Provider Name (Legal Business Name): ELEMENTAL MEDSPA LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14484 JOHN HUMPHREY DR
ORLAND PARK IL
60462-2638
US

IV. Provider business mailing address

14484 JOHN HUMPHREY DR
ORLAND PARK IL
60462-2638
US

V. Phone/Fax

Practice location:
  • Phone: 708-553-0303
  • Fax: 708-364-0480
Mailing address:
  • Phone: 708-553-0303
  • Fax: 708-364-0480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARTINS ADEOYE
Title or Position: CEO
Credential: MD
Phone: 708-553-0303