Provider Demographics
NPI:1023396744
Name:LIFE WELLNESS CLINIC, INC.
Entity Type:Organization
Organization Name:LIFE WELLNESS CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MOON HONG
Authorized Official - Middle Name:
Authorized Official - Last Name:DOH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:224-545-7787
Mailing Address - Street 1:2037 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3581
Mailing Address - Country:US
Mailing Address - Phone:847-242-8047
Mailing Address - Fax:847-242-8048
Practice Address - Street 1:2037 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:RIVERWOODS
Practice Address - State:IL
Practice Address - Zip Code:60015-3581
Practice Address - Country:US
Practice Address - Phone:847-242-8047
Practice Address - Fax:847-242-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011280111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Single Specialty