Healthcare Provider Details

I. General information

NPI: 1992158562
Provider Name (Legal Business Name): ILLINOIS WELLNESS AND WEIGHT LOSS CENTERS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9933 SOUTH WESTERN AVENUE SUITE 200
CHICAGO IL
60643-1810
US

IV. Provider business mailing address

9933 SOUTH WESTERN AVENUE SUITE 200
CHICAGO IL
60643-1810
US

V. Phone/Fax

Practice location:
  • Phone: 708-325-8615
  • Fax:
Mailing address:
  • Phone: 708-325-8615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VB0002X
TaxonomyObesity Medicine (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GOLDWYN B FOGGIE
Title or Position: CEO
Credential: M.D.
Phone: 708-325-8616