=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215338066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENLIGHTEN HOLISTIC MEDICINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2014
-----------------------------------------------------
Last Update Date | 09/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5330 W DEVON AVE SUITE 5
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-4148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-682-7124
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5330 W DEVON AVE SUITE 5
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-4148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED ACUPUNCTURIST
-----------------------------------------------------
Name | KELLY MULLEN DESIERTO
-----------------------------------------------------
Credential | L.AC.
-----------------------------------------------------
Telephone | 773-682-7124
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 198.001110
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------