MEDICARE: STEPHANIE ROYAL CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1083207872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEPHANIE ROYAL CLINIC LLC

Provider Business Mailing Address
First Line	:	47 W POLK ST STE 172
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-2000
Country	:	US
Telephone Number	:	917-204-5198
Fax Number	:

Provider Business Practice Location Address
First Line	:	8239 S KING DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-4961
Country	:	US
Telephone Number	:	917-204-5198
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. STEPHANIE ROYAL
Credential	:	MS
Telephone Number	:	917-204-5198

Provider Enumeration Date	:	02/12/2021
Last Update Date	:	02/12/2021

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