Provider Demographics
NPI:1033714753
Name:EVENTIDE WELLNESS INC
Entity Type:Organization
Organization Name:EVENTIDE WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ED AND ACTING SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:708-275-0934
Mailing Address - Street 1:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-0764
Mailing Address - Country:US
Mailing Address - Phone:708-275-0934
Mailing Address - Fax:888-419-1594
Practice Address - Street 1:7021 W 153RD ST STE 5
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-5397
Practice Address - Country:US
Practice Address - Phone:708-381-5009
Practice Address - Fax:888-419-1594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)