MEDICARE: THE WEAVE LUXE BAR

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1134748767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE WEAVE LUXE BAR

Provider Business Mailing Address
First Line	:	7315 LEMONT RD
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60516-3807
Country	:	US
Telephone Number	:	630-506-1551
Fax Number	:	252-650-6564

Provider Business Practice Location Address
First Line	:	7315 LEMONT RD
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60516-3807
Country	:	US
Telephone Number	:	630-506-1551
Fax Number	:	252-650-6564

Authorized Official
Title or Position	:	OWNER
Name	:	SHAYLAN PITTARD
Credential	:
Telephone Number	:	630-506-1551

Provider Enumeration Date	:	04/14/2020
Last Update Date	:	04/14/2020

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Directions to “THE WEAVE LUXE BAR ” Practice Location

Language	Start Address	Practice Location

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