Provider Demographics
NPI:1770501371
Name:WELLNESSONE OF GLEN CARBON, LLC
Entity Type:Organization
Organization Name:WELLNESSONE OF GLEN CARBON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DORRITY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-288-4500
Mailing Address - Street 1:4517 S STATE ROUTE 159
Mailing Address - Street 2:STE 4
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1584
Mailing Address - Country:US
Mailing Address - Phone:618-288-4500
Mailing Address - Fax:
Practice Address - Street 1:4517 S STATE ROUTE 159
Practice Address - Street 2:STE 4
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1584
Practice Address - Country:US
Practice Address - Phone:618-288-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty