Provider Demographics
NPI:1346515244
Name:VITA NOBLESSE INC.
Entity Type:Organization
Organization Name:VITA NOBLESSE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:D'LOREYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-941-1174
Mailing Address - Street 1:6006 W. 159TH ST
Mailing Address - Street 2:BLDG A, STE 2B/WEST
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2904
Mailing Address - Country:US
Mailing Address - Phone:708-941-1174
Mailing Address - Fax:
Practice Address - Street 1:6006 W. 159TH ST
Practice Address - Street 2:BLDG A, STE 2B/WEST
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-2904
Practice Address - Country:US
Practice Address - Phone:708-941-1174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.126980261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health