Provider Demographics
NPI:1013210269
Name:JEREMY BONSOL,LLC
Entity Type:Organization
Organization Name:JEREMY BONSOL,LLC
Other - Org Name:ALIGNED MODERN HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BONSOL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-663-5351
Mailing Address - Street 1:3514 N SOUTHPORT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1436
Mailing Address - Country:US
Mailing Address - Phone:773-248-2544
Mailing Address - Fax:505-213-3515
Practice Address - Street 1:3514 N SOUTHPORT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-1436
Practice Address - Country:US
Practice Address - Phone:773-248-2544
Practice Address - Fax:505-213-3515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center