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General NPI Number Information
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NPI Number | 1730823162
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Entity Type | Organization
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Legal Business Name | PEARLS OF VEDA MEDICAL AND HOLISTIC SPA. LLC
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Dates
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Enumeration Date | 04/22/2022
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Last Update Date | 07/21/2024
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Provider Practice Location Address
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Address Line | 433 W 95TH ST
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City | CHICAGO
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State | IL
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Zip | 60628-1155
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Country | US
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Telephone | 708-879-3043
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Fax | 855-640-4865
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Provider Business Mailing Address
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Address Line | 22615 HUNTERS TRL
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City | FRANKFORT
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State | IL
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Zip | 60423-6001
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Country | US
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Telephone | 773-981-8609
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Fax |
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Authorized Official
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Title or Position | BUSINESS OWNER/MEDICAL DIRECTOR
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Name | DR. AVIDA NUBIA BUSSELL
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Credential | MD
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Telephone | 708-586-9798
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 202D00000X
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Taxonomy Name | Integrative Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2083B0002X
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Taxonomy Name | Obesity Medicine (Preventive Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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