Provider Demographics
NPI:1043085855
Name:LOGAN SQUARE ACUPUNCTURE, LLC
Entity Type:Organization
Organization Name:LOGAN SQUARE ACUPUNCTURE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, L.AC.
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSTCM
Authorized Official - Phone:773-573-2828
Mailing Address - Street 1:3600 W WRIGHTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1138
Mailing Address - Country:US
Mailing Address - Phone:773-573-2828
Mailing Address - Fax:
Practice Address - Street 1:3600 W WRIGHTWOOD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-1138
Practice Address - Country:US
Practice Address - Phone:773-292-2972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty