Healthcare Provider Details

I. General information

NPI: 1386115129
Provider Name (Legal Business Name): ASTHMA AND ALLERGY WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 FOXFIELD RD STE 203
ST CHARLES IL
60174-5799
US

IV. Provider business mailing address

1187 CLEANDER CT
NAPERVILLE IL
60540-7352
US

V. Phone/Fax

Practice location:
  • Phone: 630-884-5704
  • Fax:
Mailing address:
  • Phone: 630-247-4304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number
License Number State

VIII. Authorized Official

Name: PRIYA BANSAL
Title or Position: PRESIDENT
Credential: MD
Phone: 630-247-4304