=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457675274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREE OF LIFE WELLNESS CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2010
-----------------------------------------------------
Last Update Date | 04/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 551 S SPRING RD
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-3859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-941-8733
-----------------------------------------------------
Fax | 630-941-8731
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 551 S SPRING RD
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-3859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-941-8733
-----------------------------------------------------
Fax | 630-941-8731
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. KELLY SYNOWIEC-MORONEY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 630-941-8733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038008964
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------