Provider Demographics
NPI:1639357726
Name:VITALIZE CHIROPRACTIC: A CREATING WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:VITALIZE CHIROPRACTIC: A CREATING WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:KILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-624-9080
Mailing Address - Street 1:4980 BENCHMARK CENTRE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2041
Mailing Address - Country:US
Mailing Address - Phone:618-624-9080
Mailing Address - Fax:618-624-9090
Practice Address - Street 1:4980 BENCHMARK CENTRE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2041
Practice Address - Country:US
Practice Address - Phone:618-624-9080
Practice Address - Fax:618-624-9090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011081111N00000X
IL38008365111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty