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General NPI Number Information
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NPI Number | 1295296572
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Entity Type | Organization
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Legal Business Name | PHYSICIANS HEALING AT HOME LLC
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Dates
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Enumeration Date | 03/28/2019
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Last Update Date | 03/28/2019
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Provider Practice Location Address
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Address Line | 7011 S CREGIER AVE
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City | CHICAGO
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State | IL
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Zip | 60649-1911
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Country | US
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Telephone | 773-314-7090
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 490848
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City | CHICAGO
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State | IL
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Zip | 60649-0048
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Country | US
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Telephone | 773-314-7090
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CAMILLE STACKHOUSE
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Credential | MBR
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Telephone | 177-331-4709
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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 |
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License Number State |
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