Provider Demographics
NPI:1114357811
Name:WELLNESS INTEGRATIVE MEDICINE, INC
Entity Type:Organization
Organization Name:WELLNESS INTEGRATIVE MEDICINE, INC
Other - Org Name:WELLNESS INTEGRATIVE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-960-2986
Mailing Address - Street 1:18036 GOTTSCHALK AVE
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-1712
Mailing Address - Country:US
Mailing Address - Phone:708-960-2986
Mailing Address - Fax:855-869-8599
Practice Address - Street 1:18036 GOTTSCHALK AVE
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1712
Practice Address - Country:US
Practice Address - Phone:708-960-2986
Practice Address - Fax:855-869-8599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103914261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH18186Medicare UPIN