Provider Demographics
NPI:1710304787
Name:CRYSTAL LAKE FAMILY WELLNESS
Entity Type:Organization
Organization Name:CRYSTAL LAKE FAMILY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:484-354-4289
Mailing Address - Street 1:4777 NORTHWEST HWY
Mailing Address - Street 2:UNIT C
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7340
Mailing Address - Country:US
Mailing Address - Phone:815-788-7504
Mailing Address - Fax:815-788-7508
Practice Address - Street 1:4777 NORTHWEST HWY
Practice Address - Street 2:UNIT C
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7340
Practice Address - Country:US
Practice Address - Phone:815-788-7504
Practice Address - Fax:815-788-7508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012416111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty