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General NPI Number Information
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NPI Number | 1902391360
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Entity Type | Organization
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Legal Business Name | BODHI & SAGE, LLC
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Dates
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Enumeration Date | 06/28/2018
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Last Update Date | 06/28/2018
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Provider Practice Location Address
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Address Line | 1525 E 53RD ST STE 808
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City | CHICAGO
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State | IL
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Zip | 60615-4583
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Country | US
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Telephone | 312-403-1853
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Fax | 773-947-0084
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Provider Business Mailing Address
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Address Line | 1525 E 53RD ST STE 808
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City | CHICAGO
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State | IL
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Zip | 60615-4583
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Country | US
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Telephone | 312-403-1853
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Fax | 773-947-0084
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Authorized Official
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Title or Position | FOUNDER & CLINIC DIRECTOR
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Name | ROGER FONG
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Credential | PT, LAC
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Telephone | 312-403-1853
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 198001289
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License Number State | IL
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