=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942574959
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSAL WELLNESS SOURCE AT LAKESHORE EAST SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2012
-----------------------------------------------------
Last Update Date | 09/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 E BENTON PL 104
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60601-7412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-578-5133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5501 S 208TH CIR
-----------------------------------------------------
City | ELKHORN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68022-3138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-578-5133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER/CHIROPRACTIC DOCTOR
-----------------------------------------------------
Name | DR. KAYLYNNE M GASIOROWSKI
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 402-578-5133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------