Provider Demographics
NPI:1629373212
Name:ADVANCED WELLNESS CLINICS
Entity Type:Organization
Organization Name:ADVANCED WELLNESS CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HELENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUIZ-PLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:708-450-0705
Mailing Address - Street 1:1835 N BROADWAY AVENUE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160
Mailing Address - Country:US
Mailing Address - Phone:708-450-0705
Mailing Address - Fax:
Practice Address - Street 1:1835 N BROADWAY AVENUE
Practice Address - Street 2:SUITE 104
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160
Practice Address - Country:US
Practice Address - Phone:708-450-0705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074432207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079717Medicaid
IL0031603786OtherBC BS
IL0031603786OtherBC BS
ILK12715Medicare PIN