Provider Demographics
NPI:1760714448
Name:WELLNESS SPECIALISTS, CORP
Entity Type:Organization
Organization Name:WELLNESS SPECIALISTS, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:G
Authorized Official - Last Name:GONZAGA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:630-780-6956
Mailing Address - Street 1:330 E ROOSEVELT RD
Mailing Address - Street 2:STE 2B4
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4644
Mailing Address - Country:US
Mailing Address - Phone:630-780-6956
Mailing Address - Fax:630-873-2041
Practice Address - Street 1:330 E ROOSEVELT RD
Practice Address - Street 2:STE 2B4
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4640
Practice Address - Country:US
Practice Address - Phone:630-780-6956
Practice Address - Fax:630-873-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1011185251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1011185OtherSTATE LICENSE