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General NPI Number Information
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NPI Number | 1568778678
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Entity Type | Organization
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Legal Business Name | VANDEVELDE WELLNESS CENTER SC
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Dates
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Enumeration Date | 08/26/2010
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Last Update Date | 05/10/2013
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Provider Practice Location Address
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Address Line | 615 HOLLIS ST
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City | KEWANEE
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State | IL
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Zip | 61443-3730
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Country | US
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Telephone | 309-852-3939
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Fax | 309-852-3911
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Provider Business Mailing Address
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Address Line | 615 HOLLIS ST
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City | KEWANEE
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State | IL
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Zip | 61443-3730
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Country | US
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Telephone | 309-852-3939
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Fax | 309-852-3911
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Authorized Official
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Title or Position | OWNER
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Name | CHAD VANDEVELDE
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Credential |
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Telephone | 309-852-3939
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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 | 038-011053
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License Number State | IL
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