Provider Demographics
NPI:1790280949
Name:NORTHCENTER HEALTH AND WELLNESS, LLC
Entity Type:Organization
Organization Name:NORTHCENTER HEALTH AND WELLNESS, LLC
Other - Org Name:NORTHCENTER HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:SUNGSOON
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-208-6594
Mailing Address - Street 1:4535 E LARCH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-1454
Mailing Address - Country:US
Mailing Address - Phone:847-208-6594
Mailing Address - Fax:
Practice Address - Street 1:4045 N DAMEN AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3277
Practice Address - Country:US
Practice Address - Phone:773-296-2766
Practice Address - Fax:773-296-2768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013059111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty