=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780124982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | META MODERN HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2017
-----------------------------------------------------
Last Update Date | 03/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 925 N LARRABEE ST C-1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-874-7177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 925 N LARRABEE ST C-1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | STEPHANIE NELSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-874-7177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------