Provider Demographics
NPI:1558773077
Name:BOTELLO, RUBY (LMT)
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:BOTELLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N CLINTON ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-2386
Mailing Address - Country:US
Mailing Address - Phone:312-818-1901
Mailing Address - Fax:312-488-4628
Practice Address - Street 1:118 N CLINTON ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-2386
Practice Address - Country:US
Practice Address - Phone:312-818-1901
Practice Address - Fax:312-488-4628
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227009901225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist