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General NPI Number Information
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NPI Number | 1043468440
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Entity Type | Organization
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Legal Business Name | HOLISTIC FAMILY MEDICINE
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Dates
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Enumeration Date | 08/28/2008
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Last Update Date | 08/28/2008
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Provider Practice Location Address
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Address Line | 11110 S SAWYER AVE
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City | CHICAGO
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State | IL
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Zip | 60655-2724
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Country | US
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Telephone | 773-881-7191
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Fax |
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Provider Business Mailing Address
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Address Line | 1647 W 105TH PL
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City | CHICAGO
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State | IL
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Zip | 60643-2915
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Country | US
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Telephone | 773-881-7191
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LARRY JENKINS
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Credential |
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Telephone | 312-953-0547
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036094988
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License Number State | IL
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