Provider Demographics
NPI:1275105967
Name:SUPREME WELLNESS AESTHETICS & RECOVERY INC
Entity Type:Organization
Organization Name:SUPREME WELLNESS AESTHETICS & RECOVERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVONE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:630-635-6633
Mailing Address - Street 1:678 N NORTHWEST HWY STE C
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-2540
Mailing Address - Country:US
Mailing Address - Phone:847-653-6191
Mailing Address - Fax:
Practice Address - Street 1:678 N NORTHWEST HWY STE C
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-2540
Practice Address - Country:US
Practice Address - Phone:847-653-6191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-13
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty