Healthcare Provider Details

I. General information

NPI: 1770967564
Provider Name (Legal Business Name): GREENPATH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1749 S NAPERVILLE RD STE 207
WHEATON IL
60189-5892
US

IV. Provider business mailing address

1749 S NAPERVILLE RD STE 207
WHEATON IL
60189-5892
US

V. Phone/Fax

Practice location:
  • Phone: 630-460-6733
  • Fax:
Mailing address:
  • Phone: 630-460-6733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. OLGA ROSHIOR
Title or Position: OWNER
Credential: D.C.
Phone: 630-460-6733