Provider Demographics
NPI:1659603611
Name:WELLNESS RESTORATION CENTERS OF ILLINOIS, LLC
Entity Type:Organization
Organization Name:WELLNESS RESTORATION CENTERS OF ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDEE
Authorized Official - Middle Name:P
Authorized Official - Last Name:VAN NESS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:719-651-5102
Mailing Address - Street 1:700A S ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-2142
Mailing Address - Country:US
Mailing Address - Phone:618-277-6300
Mailing Address - Fax:618-277-6302
Practice Address - Street 1:700A S ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-2142
Practice Address - Country:US
Practice Address - Phone:618-277-6300
Practice Address - Fax:618-277-6302
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAN NESS ENTREPRISES, LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty