Healthcare Provider Details

I. General information

NPI: 1477380426
Provider Name (Legal Business Name): RELLA J GRUBEK COSMETOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 DANADA SQ W
WHEATON IL
60189-2000
US

IV. Provider business mailing address

80 DANADA SQ W
WHEATON IL
60189-2000
US

V. Phone/Fax

Practice location:
  • Phone: 630-668-1118
  • Fax:
Mailing address:
  • Phone: 630-668-1118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number011-253076
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: