Provider Demographics
NPI:1225279680
Name:DR. TRACEY KINIGAKIS,M.D.- YOUR WELLNESS PARTNER,LLC
Entity Type:Organization
Organization Name:DR. TRACEY KINIGAKIS,M.D.- YOUR WELLNESS PARTNER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:KINIGAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-618-8116
Mailing Address - Street 1:1495 NORTHROCK CT
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-1233
Mailing Address - Country:US
Mailing Address - Phone:815-618-8116
Mailing Address - Fax:
Practice Address - Street 1:1495 NORTHROCK CT
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-1233
Practice Address - Country:US
Practice Address - Phone:815-618-8116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-095213261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care