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General NPI Number Information
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NPI Number | 1851551048
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Entity Type | Organization
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Legal Business Name | DIRECT ALPHA HEALTH CORP
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Dates
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Enumeration Date | 06/11/2008
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Last Update Date | 06/11/2008
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Provider Practice Location Address
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Address Line | 19900 GOVERNORS DR STE 16
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City | OLYMPIA FIELDS
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State | IL
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Zip | 60461-1059
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Country | US
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Telephone | 708-283-2511
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Fax |
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Provider Business Mailing Address
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Address Line | 19900 GOVERNORS DR STE 16
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City | OLYMPIA FIELDS
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State | IL
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Zip | 60461-1059
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Country | US
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Telephone | 708-283-2511
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. J B TATE
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Credential |
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Telephone | 708-283-2511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | 004.002239
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License Number State | IL
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