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General NPI Number Information
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NPI Number | 1306073747
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Entity Type | Organization
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Legal Business Name | ANCIENT HEALING ORIENTAL MEDICINE CLINIC S.C.
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Dates
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Enumeration Date | 06/11/2009
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Last Update Date | 01/25/2011
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Provider Practice Location Address
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Address Line | 987 OAK KNOLL DR.
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City | LAKE FOREST
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State | IL
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Zip | 60045-2635
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Country | US
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Telephone | 847-735-9609
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Fax | 847-235-2439
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Provider Business Mailing Address
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Address Line | 987 OAK KNOLL DR
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City | LAKE FOREST
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State | IL
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Zip | 60045-2635
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Country | US
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Telephone | 847-735-9609
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Fax | 847-235-2439
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. WIOLETTA BORECKA-KOLCAN
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Credential | MD, OMD, L.AC.
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Telephone | 773-562-0734
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 198000814
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 03801172
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 198.000814
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License Number State | IL
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