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General NPI Number Information
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NPI Number | 1568980456
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Entity Type | Organization
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Legal Business Name | DEMI'S FITNESS AND LEARNING ACADEMY NFP
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Dates
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Enumeration Date | 08/31/2017
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 4901 S DREXEL BLVD APT 226
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City | CHICAGO
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State | IL
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Zip | 60615-2763
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Country | US
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Telephone | 872-333-1050
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Fax |
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Provider Business Mailing Address
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Address Line | 4901 S DREXEL BLVD APT 226
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City | CHICAGO
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State | IL
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Zip | 60615-2763
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DEVELOPMENTAL THERAPIST
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Name | KOKO BURRUSS
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Credential | DT
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Telephone | 872-333-1050
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number | KB21490817P
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License Number State | IL
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