=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043085855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOGAN SQUARE ACUPUNCTURE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2023
-----------------------------------------------------
Last Update Date | 11/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 W WRIGHTWOOD AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-1138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-292-2972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3600 W WRIGHTWOOD AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-1138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-573-2828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, L.AC.
-----------------------------------------------------
Name | MS. KIMBERLY A SULLIVAN
-----------------------------------------------------
Credential | MSTCM
-----------------------------------------------------
Telephone | 773-573-2828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------