Healthcare Provider Details

I. General information

NPI: 1467364380
Provider Name (Legal Business Name): CROWN N GLOW CRANIAL PROSTHESIS COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 SAUK TRL
RICHTON PARK IL
60471-1339
US

IV. Provider business mailing address

3911 SAUK TRL
RICHTON PARK IL
60471-1339
US

V. Phone/Fax

Practice location:
  • Phone: 708-965-3118
  • Fax:
Mailing address:
  • Phone: 708-965-3118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: ISHA WARDELL
Title or Position: PRESIDENT
Credential:
Phone: 708-724-8715