Provider Demographics
NPI:1316495534
Name:HEALING SPACE, LLC
Entity type:Organization
Organization Name:HEALING SPACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-304-5526
Mailing Address - Street 1:2075 FOXFIELD RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1402
Mailing Address - Country:US
Mailing Address - Phone:847-304-5526
Mailing Address - Fax:630-549-0527
Practice Address - Street 1:2075 FOXFIELD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1402
Practice Address - Country:US
Practice Address - Phone:847-304-5526
Practice Address - Fax:630-549-0527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty