MEDICARE: THE WELLNESS SOURCE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1033429295
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE WELLNESS SOURCE LLC

Provider Business Mailing Address
First Line	:	1245 MILWAUKEE AVE
Second Line	:	202
City	:	GLENVIEW
State	:	IL
Zip	:	60025-2400
Country	:	US
Telephone Number	:	224-567-8580
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 W VAN BUREN ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-3520
Country	:	US
Telephone Number	:	661-378-8132
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DENNIS JAMES LOPEZ
Credential	:	D.C.
Telephone Number	:	661-378-8132

Provider Enumeration Date	:	10/20/2010
Last Update Date	:	09/19/2013

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Directions to “THE WELLNESS SOURCE LLC ” Practice Location

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