Provider Demographics
NPI:1083763866
Name:FAMILY WELLNESS CLINIC LTD
Entity Type:Organization
Organization Name:FAMILY WELLNESS CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-632-1680
Mailing Address - Street 1:410 E NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3305
Mailing Address - Country:US
Mailing Address - Phone:847-632-1680
Mailing Address - Fax:847-632-1681
Practice Address - Street 1:410 E NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3305
Practice Address - Country:US
Practice Address - Phone:847-632-1680
Practice Address - Fax:847-632-1681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101711207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101711Medicaid
IL036101711Medicaid