Provider Demographics
NPI:1598920977
Name:PRESCRIPTIVE WELLNESS LLC
Entity Type:Organization
Organization Name:PRESCRIPTIVE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-404-0160
Mailing Address - Street 1:3330 W 177TH ST STE 3F
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2197
Mailing Address - Country:US
Mailing Address - Phone:773-404-0160
Mailing Address - Fax:
Practice Address - Street 1:3330 W 177TH ST STE 3F
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2197
Practice Address - Country:US
Practice Address - Phone:773-404-0160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361066142081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty