MEDICARE: WELLNESS REVOLUTION LAKEVIEW 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	:	1063920916
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS REVOLUTION LAKEVIEW LLC

Provider Business Mailing Address
First Line	:	3464 N LINCOLN AVE # G1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1173
Country	:	US
Telephone Number	:	773-348-6908
Fax Number	:	224-477-2617

Provider Business Practice Location Address
First Line	:	3464 N LINCOLN AVE # G1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1173
Country	:	US
Telephone Number	:	773-348-6908
Fax Number	:	224-477-2617

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ANTHONY BREITBACH
Credential	:	DC
Telephone Number	:	847-869-1773

Provider Enumeration Date	:	01/12/2018
Last Update Date	:	08/28/2025

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