Provider Demographics
NPI:1932700770
Name:BROADLEAF HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:BROADLEAF HEALTH AND WELLNESS
Other - Org Name:BROADLEAF HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REHAB PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPEJO
Authorized Official - Suffix:
Authorized Official - Credentials:OT/CCCPA
Authorized Official - Phone:773-947-4607
Mailing Address - Street 1:3245 GROVE AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3476
Mailing Address - Country:US
Mailing Address - Phone:773-947-4607
Mailing Address - Fax:
Practice Address - Street 1:3245 GROVE AVE STE 205
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3476
Practice Address - Country:US
Practice Address - Phone:773-947-4607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-06
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00OtherPERSONAL INSURANCE
IL00Medicaid