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General NPI Number Information
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NPI Number | 1508392580
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Entity Type | Organization
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Legal Business Name | ODYSSEY WELLNESS, LLC
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 24W500 MAPLE AVE 116
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City | NAPERVILLE
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State | IL
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Zip | 60540-6055
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Country | US
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Telephone | 815-343-0510
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Fax |
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Provider Business Mailing Address
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Address Line | 24W500 MAPLE AVE 116
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City | NAPERVILLE
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State | IL
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Zip | 60540-6055
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Country | US
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Telephone | 815-343-0510
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. RICHARD BALDENEGRO
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Credential | D.C.
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Telephone | 815-343-0510
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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 | 038.011061
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License Number State | IL
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