Provider Demographics
NPI:1275751745
Name:WELLNESSONE OF FAIRVIEW HEIGHTS, LLC
Entity Type:Organization
Organization Name:WELLNESSONE OF FAIRVIEW HEIGHTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:M
Authorized Official - Last Name:DORRITY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-398-9716
Mailing Address - Street 1:10607 LINCOLN TRL
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-1913
Mailing Address - Country:US
Mailing Address - Phone:618-310-1600
Mailing Address - Fax:618-688-1091
Practice Address - Street 1:10607 LINCOLN TRL
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-1913
Practice Address - Country:US
Practice Address - Phone:618-310-1600
Practice Address - Fax:618-688-1091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03800888111N00000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08232177OtherBCBS GROUP NUMBER
IL212885Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER