Provider Demographics
NPI:1508157348
Name:WELLNESS CHICAGO COMPLEMENTARY MEDICAL CENTERS
Entity Type:Organization
Organization Name:WELLNESS CHICAGO COMPLEMENTARY MEDICAL CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:DEARINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-467-0678
Mailing Address - Street 1:820 N ORLEANS ST
Mailing Address - Street 2:SUITE 345
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-3132
Mailing Address - Country:US
Mailing Address - Phone:312-467-0678
Mailing Address - Fax:
Practice Address - Street 1:1101 LAKE ST
Practice Address - Street 2:SUITE 350
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1085
Practice Address - Country:US
Practice Address - Phone:312-467-0678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005791261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038-005791OtherILLINOIS LICENSE NUMBER
1629024518OtherINDIVIDUAL NPI
ILT39009Medicare UPIN