=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588046619
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAM WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2015
-----------------------------------------------------
Last Update Date | 08/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5002 MAIN ST
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-3659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-208-3243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5514 TENNESSEE AVE
-----------------------------------------------------
City | CLARENDON HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60514-1512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-208-3243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTIC PHYSICIAN
-----------------------------------------------------
Name | DR. RENEE A MATTHES
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 312-208-3243
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------