Healthcare Provider Details

I. General information

NPI: 1831034180
Provider Name (Legal Business Name): MDMC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 W ROSCOE ST
CHICAGO IL
60657-0320
US

IV. Provider business mailing address

1351 W ROSCOE ST
CHICAGO IL
60657-0320
US

V. Phone/Fax

Practice location:
  • Phone: 414-467-2056
  • Fax:
Mailing address:
  • Phone: 414-467-2056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY DEWOLFE
Title or Position: APRN/CO-CEO
Credential: APRN
Phone: 414-467-2056