Provider Demographics
NPI:1417928813
Name:MORAINE VALLEY WELLNESS CENTERS CHTD
Entity Type:Organization
Organization Name:MORAINE VALLEY WELLNESS CENTERS CHTD
Other - Org Name:MORAINE VALLEY CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:LUCIENNE
Authorized Official - Last Name:EHLERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-598-9010
Mailing Address - Street 1:8700 WEST 95TH STREET
Mailing Address - Street 2:SUITE 2-3
Mailing Address - City:HICKORY HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60457-2727
Mailing Address - Country:US
Mailing Address - Phone:708-598-9010
Mailing Address - Fax:708-598-9013
Practice Address - Street 1:8700 WEST 95TH STREET
Practice Address - Street 2:SUITE 2-3
Practice Address - City:HICKORY HILLS
Practice Address - State:IL
Practice Address - Zip Code:60457-2727
Practice Address - Country:US
Practice Address - Phone:708-598-9010
Practice Address - Fax:708-598-9013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004667111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1682634OtherBCBS
T37936Medicare UPIN
IL210388Medicare ID - Type Unspecified