Provider Demographics
NPI:1154920759
Name:BURDOCK & CLOVE WELLNESS LLC
Entity type:Organization
Organization Name:BURDOCK & CLOVE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LICENSED ACUPUNCTURIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VICTORINE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:312-735-3589
Mailing Address - Street 1:2052 W ADDISON ST # 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6126
Mailing Address - Country:US
Mailing Address - Phone:312-735-3589
Mailing Address - Fax:
Practice Address - Street 1:2052 W ADDISON ST # 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6126
Practice Address - Country:US
Practice Address - Phone:312-735-3589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty