MEDICARE: CLEAR RIDGE WELLNESS CENTER LTD.

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	261QP2300X	Primary Care Clinic/Center	041.283154	IL
2	261QP2300X	Primary Care Clinic/Center	209.008667	IL

General Provider Information

NPI Number	:	1174803878
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAR RIDGE WELLNESS CENTER LTD.

Provider Business Mailing Address
First Line	:	6745 W 63RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-4003
Country	:	US
Telephone Number	:	773-229-8545
Fax Number	:	773-229-8545

Provider Business Practice Location Address
First Line	:	6745 W 63RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-4003
Country	:	US
Telephone Number	:	773-229-8545
Fax Number	:	773-229-8545

Authorized Official
Title or Position	:	FAMILY NURSE PRACTITIONER
Name	:	MARGARET KAY STELLE-BETMAN
Credential	:	APN, FNP-BC
Telephone Number	:	309-287-5506

Provider Enumeration Date	:	08/25/2011
Last Update Date	:	02/13/2012

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