=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407448798
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAGE AND HEALER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2021
-----------------------------------------------------
Last Update Date | 02/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5940 N SHERIDAN RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60660-3644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-824-1427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5940 N SHERIDAN RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60660-3644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-824-1427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ABIYAH-DOV MATTISYAHU EPSTEIN
-----------------------------------------------------
Credential | LMT, CMLDT
-----------------------------------------------------
Telephone | 312-824-1427
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------