Healthcare Provider Details

I. General information

NPI: 1447530852
Provider Name (Legal Business Name): CUSTOM HEALING AND WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 SAUK TRL STE F SUITE F
RICHTON PARK IL
60471-1060
US

IV. Provider business mailing address

5111 SAUK TRL STE F SUITE F
RICHTON PARK IL
60471-1060
US

V. Phone/Fax

Practice location:
  • Phone: 708-980-2348
  • Fax:
Mailing address:
  • Phone: 708-980-2348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number051292165
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number181000392
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number051292165
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License Number051292165
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051292165
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number181000392
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number01013
License Number StateNM
# 8
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01013
License Number StateNM
# 9
Primary TaxonomyY
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number181000392
License Number StateIL

VIII. Authorized Official

Name: DR. SHANTE GRIGGS
Title or Position: CLINICAL PHARMACIST / NAPRAPATH
Credential: PHARM D, DN
Phone: 708-980-2348