Healthcare Provider Details

I. General information

NPI: 1285909200
Provider Name (Legal Business Name): ROCKFORD WELLNESS CORPORATION SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 FINCHAM ROAD
ROCKFORD IL
61108
US

IV. Provider business mailing address

6019 FINCHAM ROAD
ROCKFORD IL
61108
US

V. Phone/Fax

Practice location:
  • Phone: 815-708-0125
  • Fax: 815-316-1069
Mailing address:
  • Phone: 815-708-0125
  • Fax: 815-316-1069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number038010875
License Number StateIL

VIII. Authorized Official

Name: DR. KIMBERLY S OSBORNE
Title or Position: PRESIDENT/OWNER
Credential: DC
Phone: 815-708-0125