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General NPI Number Information
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NPI Number | 1063839488
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Entity Type | Organization
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Legal Business Name | THE WELLNESS SOURCE OF TEDDIE KOSSOF, INC
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Dates
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Enumeration Date | 03/24/2014
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Last Update Date | 01/27/2016
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Provider Practice Location Address
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Address Line | 3324 N HALSTED ST
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City | CHICAGO
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State | IL
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Zip | 60657-2413
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Country | US
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Telephone | 312-848-5668
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Fax |
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Provider Business Mailing Address
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Address Line | 3324 N HALSTED ST
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City | CHICAGO
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State | IL
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Zip | 60657-2413
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Country | US
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Telephone | 773-906-9265
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DENNIS J LOPEZ
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Credential | DC
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Telephone | 312-848-5668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 038010594
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License Number State | IL
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