Provider Demographics
NPI:1235376195
Name:ABSOLUTE WELLNESS, LTD.
Entity Type:Organization
Organization Name:ABSOLUTE WELLNESS, LTD.
Other - Org Name:LAKESIDE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TEWS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-587-0003
Mailing Address - Street 1:2 W GRAND AVE
Mailing Address - Street 2:STE 109
Mailing Address - City:FOX LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60020-1262
Mailing Address - Country:US
Mailing Address - Phone:847-587-0003
Mailing Address - Fax:847-587-0210
Practice Address - Street 1:2 W GRAND AVE
Practice Address - Street 2:STE 109
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1262
Practice Address - Country:US
Practice Address - Phone:847-587-0003
Practice Address - Fax:847-587-0210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV09971Medicare UPIN
IL214002Medicare PIN