MEDICARE: WELLNESSONE OF COLLINSVILLE

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		IL
2	225100000X	Physical Therapist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	06032162	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1760503619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESSONE OF COLLINSVILLE

Provider Business Mailing Address
First Line	:	410 REGENCY CTR
Second Line	:
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-4659
Country	:	US
Telephone Number	:	618-343-3602
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 REGENCY CTR
Second Line	:
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-4659
Country	:	US
Telephone Number	:	618-343-3602
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	SCOTT M DORRITY
Credential	:	D.C.
Telephone Number	:	618-343-3602

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	09/11/2025

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Directions to “WELLNESSONE OF COLLINSVILLE ” Practice Location

Language	Start Address	Practice Location

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