Healthcare Provider Details

I. General information

NPI: 1295960276
Provider Name (Legal Business Name): BODY GENESIS CENTER FOR INTEGRATIVE MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

937 S MANNHEIM RD
WESTCHESTER IL
60154-2552
US

IV. Provider business mailing address

937 S MANNHEIM RD
WESTCHESTER IL
60154-2552
US

V. Phone/Fax

Practice location:
  • Phone: 708-343-3368
  • Fax:
Mailing address:
  • Phone: 708-343-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number038.010603
License Number StateIL

VIII. Authorized Official

Name: DR. SOLOMON LIBURD
Title or Position: CEO/PRESIDENT
Credential: DO
Phone: 708-343-3368