=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982586970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUNTHWEST MEDSPA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2025
-----------------------------------------------------
Last Update Date | 07/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1606 W COLONIAL PKWY
-----------------------------------------------------
City | INVERNESS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60067-4738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-449-4794
-----------------------------------------------------
Fax | 630-566-4869
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9234 HARLOWE LN
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60462-1057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-449-4794
-----------------------------------------------------
Fax | 630-566-4869
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARIFE STARKEY ABISTADO
-----------------------------------------------------
Credential | FNP-C
-----------------------------------------------------
Telephone | 630-449-4794
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------