Provider Demographics
NPI:1457011306
Name:THE BLACK HOUSE GROUP LLC
Entity Type:Organization
Organization Name:THE BLACK HOUSE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & CHIEF MEDICAL PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:TEQUILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:STANCIEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-860-4814
Mailing Address - Street 1:611 S WELLS ST APT 803
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4783
Mailing Address - Country:US
Mailing Address - Phone:312-860-4814
Mailing Address - Fax:
Practice Address - Street 1:611 S WELLS ST APT 803
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4783
Practice Address - Country:US
Practice Address - Phone:312-860-4814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty