Provider Demographics
NPI:1194589432
Name:SRS MEN'S VITALITY HUB
Entity type:Organization
Organization Name:SRS MEN'S VITALITY HUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:312-437-0472
Mailing Address - Street 1:850 W BARTLETT RD STE 5C
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-4454
Mailing Address - Country:US
Mailing Address - Phone:128-728-8643
Mailing Address - Fax:
Practice Address - Street 1:7907 W 159TH ST UNIT C
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1345
Practice Address - Country:US
Practice Address - Phone:312-872-8864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty