Provider Demographics
NPI:1568778678
Name:VANDEVELDE WELLNESS CENTER SC
Entity Type:Organization
Organization Name:VANDEVELDE WELLNESS CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDEVELDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-852-3939
Mailing Address - Street 1:615 HOLLIS ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-3730
Mailing Address - Country:US
Mailing Address - Phone:309-852-3939
Mailing Address - Fax:309-852-3911
Practice Address - Street 1:615 HOLLIS ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-3730
Practice Address - Country:US
Practice Address - Phone:309-852-3939
Practice Address - Fax:309-852-3911
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VANDEVELDE WELLNESS CENTER SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-26
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-011053111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty