Provider Demographics
NPI:1558857409
Name:CHIROSSAGE WELLNESS,INC
Entity Type:Organization
Organization Name:CHIROSSAGE WELLNESS,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ILLSON
Authorized Official - Suffix:
Authorized Official - Credentials:CHIROPRACTOR
Authorized Official - Phone:949-326-7007
Mailing Address - Street 1:11 MAREBLU STE 130
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3053
Mailing Address - Country:US
Mailing Address - Phone:949-326-7007
Mailing Address - Fax:
Practice Address - Street 1:11 MAREBLU STE 130
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3053
Practice Address - Country:US
Practice Address - Phone:949-326-7007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty