Healthcare Provider Details

I. General information

NPI: 1487722716
Provider Name (Legal Business Name): APPLIED WELLNESS CENTER SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13301 S RIDGELAND AVE STE A
PALOS HEIGHTS IL
60463-0030
US

IV. Provider business mailing address

13301 S RIDGELAND AVE STE A
PALOS HEIGHTS IL
60463-0030
US

V. Phone/Fax

Practice location:
  • Phone: 708-489-3700
  • Fax: 708-489-3705
Mailing address:
  • Phone: 708-489-3700
  • Fax: 708-489-3705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number038008810
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number038.008810
License Number StateIL

VIII. Authorized Official

Name: JANELLE PATTARA
Title or Position: BILLER
Credential:
Phone: 630-890-2758