=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033736210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKYROSE REJUVENATION CLINIC & SPA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2020
-----------------------------------------------------
Last Update Date | 03/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9021 W 151ST ST
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60462-3201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-966-4258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22544 CRESCENT WAY
-----------------------------------------------------
City | RICHTON PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60471-1861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-558-9597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER/OWNER
-----------------------------------------------------
Name | MS. CHAKIKA L WILLIAMS
-----------------------------------------------------
Credential | APRN-FNP
-----------------------------------------------------
Telephone | 773-558-9597
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------