Provider Demographics
NPI:1205345337
Name:GLOW HEALTH AND WELLNESS MEDICAL SPA, PC
Entity type:Organization
Organization Name:GLOW HEALTH AND WELLNESS MEDICAL SPA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAJUANA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:630-901-2879
Mailing Address - Street 1:1001 W 15TH ST UNIT 320
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1528 W MONROE ST STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2460
Practice Address - Country:US
Practice Address - Phone:630-901-2879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008594261QI0500X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy