Provider Demographics
NPI:1093126435
Name:RAVENSWOOD HEALTH AND WELLNESS CENTER, S.C.
Entity Type:Organization
Organization Name:RAVENSWOOD HEALTH AND WELLNESS CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:GRIFFITH
Authorized Official - Last Name:FENNEMA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-456-5313
Mailing Address - Street 1:4256 N RAVENSWOOD AVE
Mailing Address - Street 2:UNIT 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1110
Mailing Address - Country:US
Mailing Address - Phone:773-327-2225
Mailing Address - Fax:773-327-7554
Practice Address - Street 1:4256 N RAVENSWOOD AVE
Practice Address - Street 2:UNIT 101
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1110
Practice Address - Country:US
Practice Address - Phone:773-327-2225
Practice Address - Fax:773-327-7554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-19
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1386657690111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty