Healthcare Provider Details

I. General information

NPI: 1205421237
Provider Name (Legal Business Name): WELL-ROOTED FUNCTIONAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S JOHNSON ST STE 207
WOODSTOCK IL
60098-3259
US

IV. Provider business mailing address

110 S JOHNSON ST STE 207
WOODSTOCK IL
60098-3259
US

V. Phone/Fax

Practice location:
  • Phone: 815-355-1605
  • Fax:
Mailing address:
  • Phone: 815-355-1605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA PAWLICKI
Title or Position: OWNER
Credential: NP
Phone: 815-529-1201