Provider Demographics
NPI:1356452726
Name:ADVANCED WELLNESS CENTER AND RESEARCH FOUNDATION
Entity Type:Organization
Organization Name:ADVANCED WELLNESS CENTER AND RESEARCH FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARGOT
Authorized Official - Middle Name:ALEXANDRA
Authorized Official - Last Name:LACAVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-695-6262
Mailing Address - Street 1:1750 N RANDALL RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-7900
Mailing Address - Country:US
Mailing Address - Phone:847-695-6262
Mailing Address - Fax:847-695-6348
Practice Address - Street 1:1750 N RANDALL RD
Practice Address - Street 2:SUITE 250
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7900
Practice Address - Country:US
Practice Address - Phone:847-695-6262
Practice Address - Fax:847-695-6348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty