Provider Demographics
NPI:1003223157
Name:ENLIVEN WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:ENLIVEN WELLNESS CENTER LLC
Other - Org Name:MASSAGE EVOLVED
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUBY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, RMT
Authorized Official - Phone:773-738-7146
Mailing Address - Street 1:118 N CLINTON ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-2386
Mailing Address - Country:US
Mailing Address - Phone:773-738-7146
Mailing Address - Fax:312-488-4628
Practice Address - Street 1:118 N CLINTON ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-2386
Practice Address - Country:US
Practice Address - Phone:773-738-7146
Practice Address - Fax:312-488-4628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227009901225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty