Healthcare Provider Details

I. General information

NPI: 1912125485
Provider Name (Legal Business Name): WELLNESSONE OF EAST BELLEVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1634 CARLYLE AVE
BELLEVILLE IL
62221-4558
US

IV. Provider business mailing address

1634 CARLYLE AVE
BELLEVILLE IL
62221-4558
US

V. Phone/Fax

Practice location:
  • Phone: 618-235-0777
  • Fax: 618-235-9440
Mailing address:
  • Phone: 618-235-0777
  • Fax: 618-235-9440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name: SCOTT M DORRITY
Title or Position: MANAGING EMPLOYEE
Credential: D.C.
Phone: 618-398-9716