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General NPI Number Information
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NPI Number | 1649651951
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Entity Type | Organization
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Legal Business Name | WELLNESS INSTITUTE OF ILLINOIS, LTD.
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Dates
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Enumeration Date | 06/11/2015
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Last Update Date | 09/01/2016
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Provider Practice Location Address
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Address Line | 741 S MCHENRY AVE STE G
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-7445
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Country | US
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Telephone | 815-477-8844
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Fax | 815-308-3387
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Provider Business Mailing Address
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Address Line | 741 S MCHENRY AVE STE G
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-7445
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Country | US
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Telephone | 815-477-8844
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Fax | 815-308-3387
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | LAWRENCE LAVINE I
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Credential | M.D.
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Telephone | 815-477-8844
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number | 036-049364
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License Number State | IL
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