Provider Demographics
NPI:1265827984
Name:DR. KWON BLUE MOUNTAIN WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:DR. KWON BLUE MOUNTAIN WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:YIHYUN
Authorized Official - Middle Name:
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-439-6161
Mailing Address - Street 1:22W385 BALSAM DR
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-7305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23909 W RENWICK RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-2108
Practice Address - Country:US
Practice Address - Phone:815-439-6161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009785111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty