MEDICARE: PRO-HOLISTIC INSTITUTE S.C.

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	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1891727145	OTHER	IL	RAE BOUVIN NPI
2	1750466991	OTHER	IL	EDGARDO VARGAS NPI

General Provider Information

NPI Number	:	1093956229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO-HOLISTIC INSTITUTE S.C.

Provider Business Mailing Address
First Line	:	2343 W MONTROSE AVE
Second Line	:	UNIT A
City	:	CHICAGO
State	:	IL
Zip	:	60618-1866
Country	:	US
Telephone Number	:	773-739-9017
Fax Number	:

Provider Business Practice Location Address
First Line	:	2343 W MONTROSE AVE
Second Line	:	UNIT A
City	:	CHICAGO
State	:	IL
Zip	:	60618-1866
Country	:	US
Telephone Number	:	773-739-9017
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RAE M BOUVIN
Credential	:	D.C.
Telephone Number	:	773-739-9017

Provider Enumeration Date	:	03/18/2009
Last Update Date	:	03/18/2009

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