Provider Demographics
NPI:1548385933
Name:GONZAGA LTD
Entity Type:Organization
Organization Name:GONZAGA LTD
Other - Org Name:SIMPLE BALANCE HOLISTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAENA
Authorized Official - Middle Name:
Authorized Official - Last Name:STANLEY-GONZAGA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-468-6012
Mailing Address - Street 1:221 E CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-6502
Mailing Address - Country:US
Mailing Address - Phone:847-468-6012
Mailing Address - Fax:847-468-6013
Practice Address - Street 1:221 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-6502
Practice Address - Country:US
Practice Address - Phone:847-468-6012
Practice Address - Fax:847-468-6013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008895111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty