Provider Demographics
NPI:1043438476
Name:LEADING EDGE HEALTH & WELLNESS DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:LEADING EDGE HEALTH & WELLNESS DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:GILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-941-5117
Mailing Address - Street 1:1013 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1510
Mailing Address - Country:US
Mailing Address - Phone:815-941-5117
Mailing Address - Fax:815-941-5118
Practice Address - Street 1:1013 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1510
Practice Address - Country:US
Practice Address - Phone:815-941-5117
Practice Address - Fax:815-941-5118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2008-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010842111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty