Provider Demographics
NPI:1275926123
Name:HEART OF TRANSFORMATION WELLNESS INSTITUTE SC
Entity Type:Organization
Organization Name:HEART OF TRANSFORMATION WELLNESS INSTITUTE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ARCHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAL-TABAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-425-9355
Mailing Address - Street 1:1618 ORRINGTON AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-5016
Mailing Address - Country:US
Mailing Address - Phone:847-425-9355
Mailing Address - Fax:847-424-9765
Practice Address - Street 1:1618 ORRINGTON AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5016
Practice Address - Country:US
Practice Address - Phone:847-425-9355
Practice Address - Fax:847-424-9765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042.619453261Q00000X
IL036.079471261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center