Healthcare Provider Details

I. General information

NPI: 1770117475
Provider Name (Legal Business Name): WYELLIS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 W COURT ST
KANKAKEE IL
60901-3216
US

IV. Provider business mailing address

1607 W COURT ST
KANKAKEE IL
60901-3216
US

V. Phone/Fax

Practice location:
  • Phone: 815-450-7100
  • Fax: 815-401-5821
Mailing address:
  • Phone: 815-450-7100
  • Fax: 815-401-5821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALFRETA DANIEL
Title or Position: BILLING MANAGER
Credential:
Phone: 815-450-7100