Provider Demographics
NPI:1033429295
Name:THE WELLNESS SOURCE LLC
Entity Type:Organization
Organization Name:THE WELLNESS SOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:661-378-8132
Mailing Address - Street 1:1245 MILWAUKEE AVE
Mailing Address - Street 2:202
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2400
Mailing Address - Country:US
Mailing Address - Phone:224-567-8580
Mailing Address - Fax:
Practice Address - Street 1:920 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-3520
Practice Address - Country:US
Practice Address - Phone:661-378-8132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty