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General NPI Number Information
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NPI Number | 1467074617
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Entity Type | Organization
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Legal Business Name | DEWOLFE AESTHETIC SERVICES SC
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Dates
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Enumeration Date | 05/11/2020
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Last Update Date | 05/11/2020
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Provider Practice Location Address
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Address Line | 3357 N. SOUTHPORT AVEUNE
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City | CHICAGO
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State | IL
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Zip | 60657
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Country | US
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Telephone | 434-284-8770
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Fax | 914-206-4144
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Provider Business Mailing Address
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Address Line | 3357 N. SOUTHPORT AVEUNE
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City | CHICAGO
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State | IL
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Zip | 60657
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Country | US
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Telephone | 434-284-8770
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Fax | 914-206-4144
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | JUDITH POLHEMUS
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Credential |
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Telephone | 434-284-8770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number |
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License Number State |
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