Provider Demographics
NPI:1902391360
Name:BODHI & SAGE, LLC
Entity Type:Organization
Organization Name:BODHI & SAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:PT, LAC
Authorized Official - Phone:312-403-1853
Mailing Address - Street 1:1525 E 53RD ST STE 808
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4583
Mailing Address - Country:US
Mailing Address - Phone:312-403-1853
Mailing Address - Fax:773-947-0084
Practice Address - Street 1:1525 E 53RD ST STE 808
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4583
Practice Address - Country:US
Practice Address - Phone:312-403-1853
Practice Address - Fax:773-947-0084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001289171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty