Provider Demographics
NPI:1689951055
Name:THE ALTERNATIVE WELLNESS CENTER
Entity Type:Organization
Organization Name:THE ALTERNATIVE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-684-4200
Mailing Address - Street 1:920 LAMBERT ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-3413
Mailing Address - Country:US
Mailing Address - Phone:269-684-4200
Mailing Address - Fax:269-262-0943
Practice Address - Street 1:920 LAMBERT ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-3413
Practice Address - Country:US
Practice Address - Phone:269-684-4200
Practice Address - Fax:269-262-0943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-13
Last Update Date:2011-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008841111N00000X, 111NN1001X, 111NR0400X
IN08001868A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200258400Medicaid
INU77091Medicare UPIN