Provider Demographics
NPI:1710035183
Name:WELLNESS REVOLUTION CHIROPRACTIC & ACUPUNCTURE CENTER
Entity Type:Organization
Organization Name:WELLNESS REVOLUTION CHIROPRACTIC & ACUPUNCTURE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BREITBACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-869-1773
Mailing Address - Street 1:1117 EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3131
Mailing Address - Country:US
Mailing Address - Phone:847-869-1773
Mailing Address - Fax:
Practice Address - Street 1:1117 EMERSON ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-869-1773
Practice Address - Fax:847-869-2733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1063920316OtherGROUP NPI
IL1255400453OtherNPI- PERSONSAL
IL1063920316OtherGROUP NPI
ILK12537Medicare UPIN