=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891528816
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEVEL UP MEDICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2024
-----------------------------------------------------
Last Update Date | 08/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1105 W 104TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-3052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-401-1508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1130 S CANAL ST # 1347
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60607-4907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KENDRA S WINSTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-401-1508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247ZC0005X
-----------------------------------------------------
Taxonomy Name | Clinical Laboratory Director (Non-physician)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------