Provider Demographics
NPI:1063839488
Name:THE WELLNESS SOURCE OF TEDDIE KOSSOF, INC
Entity Type:Organization
Organization Name:THE WELLNESS SOURCE OF TEDDIE KOSSOF, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-848-5668
Mailing Address - Street 1:3324 N HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2413
Mailing Address - Country:US
Mailing Address - Phone:773-906-9265
Mailing Address - Fax:
Practice Address - Street 1:3324 N HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2413
Practice Address - Country:US
Practice Address - Phone:312-848-5668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010594111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty