=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952709891
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NIRVANA NATUROPATHICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2014
-----------------------------------------------------
Last Update Date | 04/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 SHERMER RD STE LL29
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-5351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-715-9044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 905 TAMER LN
-----------------------------------------------------
City | GLENVIEW
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60025-3768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LANA MOSHKOVICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-508-1470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 1740686492
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------