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General NPI Number Information
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NPI Number | 1093126435
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Entity Type | Organization
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Legal Business Name | RAVENSWOOD HEALTH AND WELLNESS CENTER, S.C.
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Dates
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Enumeration Date | 05/19/2014
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Last Update Date | 12/30/2014
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Provider Practice Location Address
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Address Line | 4256 N RAVENSWOOD AVE UNIT 101
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City | CHICAGO
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State | IL
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Zip | 60613-1110
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Country | US
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Telephone | 773-327-2225
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Fax | 773-327-7554
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Provider Business Mailing Address
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Address Line | 4256 N RAVENSWOOD AVE UNIT 101
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City | CHICAGO
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State | IL
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Zip | 60613-1110
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Country | US
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Telephone | 773-327-2225
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Fax | 773-327-7554
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JASON GRIFFITH FENNEMA
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Credential | D.C.
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Telephone | 773-456-5313
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 1386657690
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License Number State | IL
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