Provider Demographics
NPI:1508392580
Name:ODYSSEY WELLNESS, LLC
Entity Type:Organization
Organization Name:ODYSSEY WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDENEGRO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-343-0510
Mailing Address - Street 1:24W500 MAPLE AVE
Mailing Address - Street 2:116
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6055
Mailing Address - Country:US
Mailing Address - Phone:815-343-0510
Mailing Address - Fax:
Practice Address - Street 1:24W500 MAPLE AVE
Practice Address - Street 2:116
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6055
Practice Address - Country:US
Practice Address - Phone:815-343-0510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011061111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty