Provider Demographics
NPI:1003196973
Name:WELLLIFE-A SUBSIDIARY OF INNOVATIVE SUSTAINABLE SOLUTIONS
Entity Type:Organization
Organization Name:WELLLIFE-A SUBSIDIARY OF INNOVATIVE SUSTAINABLE SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLERKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV
Authorized Official - Phone:773-531-5163
Mailing Address - Street 1:15808 CLIFTON PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MARKHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60428-3921
Mailing Address - Country:US
Mailing Address - Phone:773-531-5163
Mailing Address - Fax:
Practice Address - Street 1:15808 CLIFTON PARK AVE
Practice Address - Street 2:
Practice Address - City:MARKHAM
Practice Address - State:IL
Practice Address - Zip Code:60428-3921
Practice Address - Country:US
Practice Address - Phone:773-531-5163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNOVATIVE SUSTAINABLE SOLUTIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-24
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health