Provider Demographics
NPI:1568091098
Name:INTENTIONAL LIVING LLC
Entity Type:Organization
Organization Name:INTENTIONAL LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-566-8417
Mailing Address - Street 1:1841 N MONTICELLO AVE APT 1E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4741
Mailing Address - Country:US
Mailing Address - Phone:630-392-8628
Mailing Address - Fax:
Practice Address - Street 1:1041 N WESTERN AVE FL 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3571
Practice Address - Country:US
Practice Address - Phone:312-566-8417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)