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General NPI Number Information
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NPI Number | 1205345337
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Entity Type | Organization
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Legal Business Name | GLOW HEALTH AND WELLNESS MEDICAL SPA, PC
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Dates
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Enumeration Date | 09/20/2017
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Last Update Date | 09/20/2017
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Provider Practice Location Address
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Address Line | 1528 W MONROE ST STE 100
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City | CHICAGO
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State | IL
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Zip | 60607-2460
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Country | US
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Telephone | 630-901-2879
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Fax |
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Provider Business Mailing Address
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Address Line | 1001 W 15TH ST UNIT 320
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City | CHICAGO
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State | IL
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Zip | 60608-2778
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER, MANAGER
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Name | MS. TAJUANA D. JOHNSON
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Credential | FNP
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Telephone | 630-901-2879
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number | 209008594
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 209008594
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License Number State | IL
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