MEDICARE: WELLNESS WAY BURR RIDGE 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	:	1801458476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS WAY BURR RIDGE LLC

Provider Business Mailing Address
First Line	:	16W343 83RD ST STE D
Second Line	:
City	:	BURR RIDGE
State	:	IL
Zip	:	60527-7950
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16W343 83RD ST STE D
Second Line	:
City	:	BURR RIDGE
State	:	IL
Zip	:	60527-7950
Country	:	US
Telephone Number	:	630-908-7634
Fax Number	:	630-568-3194

Authorized Official
Title or Position	:	OWNER
Name	:	PATRICK FLYNN
Credential	:
Telephone Number	:	920-660-7877

Provider Enumeration Date	:	07/03/2019
Last Update Date	:	02/20/2020

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Directions to “WELLNESS WAY BURR RIDGE LLC ” Practice Location

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