Provider Demographics
NPI:1508419367
Name:WELL KEPT ELDER ENTERPRISES, LLC
Entity Type:Organization
Organization Name:WELL KEPT ELDER ENTERPRISES, LLC
Other - Org Name:WELL KEPT ELDER ENTERPRISES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:SHALISE'
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-358-8295
Mailing Address - Street 1:558 W ROOSEVELT RD # 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4917
Mailing Address - Country:US
Mailing Address - Phone:773-358-8295
Mailing Address - Fax:312-872-3562
Practice Address - Street 1:558 W ROOSEVELT RD # 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4917
Practice Address - Country:US
Practice Address - Phone:773-358-8295
Practice Address - Fax:312-872-3562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-22
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125067381Medicaid