Provider Demographics
NPI:1508077074
Name:IATGW
Entity Type:Organization
Organization Name:IATGW
Other - Org Name:WELLNESS FROM THE INSIDE OUT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:TM
Authorized Official - Last Name:DICERBO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-550-1115
Mailing Address - Street 1:765 ELA RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2385
Mailing Address - Country:US
Mailing Address - Phone:847-550-1115
Mailing Address - Fax:847-550-1117
Practice Address - Street 1:765 ELA RD
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2385
Practice Address - Country:US
Practice Address - Phone:847-550-1115
Practice Address - Fax:847-550-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212657Medicare ID - Type Unspecified