Provider Demographics
NPI:1578748067
Name:CHILDRENS WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:CHILDRENS WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-636-8747
Mailing Address - Street 1:9830 RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2667
Mailing Address - Country:US
Mailing Address - Phone:708-636-8747
Mailing Address - Fax:708-636-5854
Practice Address - Street 1:16505 106TH CT
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-4545
Practice Address - Country:US
Practice Address - Phone:708-364-1550
Practice Address - Fax:708-364-1468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079532174400000X
IL036114693174400000X
IL036115658174400000X
IL036116141174400000X
IL209010813363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1376971911OtherNPI
IL1669506390OtherNPI
IL1235263955OtherNPI
IL1912930348OtherNPI
IL1871714360OtherNPI