=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689559536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADIANT BEAUTY MED SPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2025
-----------------------------------------------------
Last Update Date | 08/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 S PRAIRIE AVE UNIT 411
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-3019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-529-5949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 S PRAIRIE AVE UNIT 411
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-3019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. BRANDON PAUL WISINSKI
-----------------------------------------------------
Credential | DO, MBA, MS
-----------------------------------------------------
Telephone | 815-529-5949
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------