Healthcare Provider Details

I. General information

NPI: 1770501371
Provider Name (Legal Business Name): WELLNESSONE OF GLEN CARBON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4517 S STATE ROUTE 159 STE 4
GLEN CARBON IL
62034-1584
US

IV. Provider business mailing address

4517 S STATE ROUTE 159 STE 4
GLEN CARBON IL
62034-1584
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-4500
  • Fax:
Mailing address:
  • Phone: 618-288-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SCOTT MICHAEL DORRITY
Title or Position: OWNER
Credential: DC
Phone: 618-288-4500