=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538302369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELLA'S BUBBLES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2009
-----------------------------------------------------
Last Update Date | 04/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 S CARPENTER ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608-4529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-929-3057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 S CARPENTER ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608-4529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-929-3057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. LAIMONIS MAGONE
-----------------------------------------------------
Credential | ETC
-----------------------------------------------------
Telephone | 312-929-3057
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------