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General NPI Number Information
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NPI Number | 1346515244
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Entity Type | Organization
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Legal Business Name | VITA NOBLESSE INC.
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Dates
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Enumeration Date | 03/12/2012
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Last Update Date | 03/12/2012
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Provider Practice Location Address
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Address Line | 6006 W. 159TH ST BLDG A, STE 2B/WEST
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City | OAK FOREST
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State | IL
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Zip | 60452-2904
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Country | US
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Telephone | 708-941-1174
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Fax |
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Provider Business Mailing Address
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Address Line | 6006 W. 159TH ST BLDG A, STE 2B/WEST
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City | OAK FOREST
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State | IL
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Zip | 60452-2904
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Country | US
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Telephone | 708-941-1174
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | D'LOREYN WALKER
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Credential | M.D.
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Telephone | 708-941-1174
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 036.126980
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 036.126980
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License Number State | IL
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