MEDICARE: TAPESTRY 360 HEALTH

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	122300000X	Dentist	019027796	IL
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1154640274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAPESTRY 360 HEALTH

Provider Business Mailing Address
First Line	:	1301 W DEVON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-1329
Country	:	US
Telephone Number	:	773-751-7800
Fax Number	:	773-539-3941

Provider Business Practice Location Address
First Line	:	3244 W AINSLIE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-5018
Country	:	US
Telephone Number	:	773-296-7589
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	NICOLE WILLIS
Credential	:
Telephone Number	:	773-751-7800

Provider Enumeration Date	:	05/28/2010
Last Update Date	:	10/20/2023

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