Provider Demographics
NPI:1942269139
Name:OPTIMUM HEALTH CHIROPRACTIC & WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:OPTIMUM HEALTH CHIROPRACTIC & WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-331-9881
Mailing Address - Street 1:PO BOX 1665
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-7665
Mailing Address - Country:US
Mailing Address - Phone:708-331-9881
Mailing Address - Fax:708-331-9876
Practice Address - Street 1:841 E 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2465
Practice Address - Country:US
Practice Address - Phone:708-331-9881
Practice Address - Fax:708-331-9876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009778111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038009778Medicaid
205967OtherMEDICARE PROVIDER #
IL01633148OtherBCBSIL
ILP00091070OtherRR MEDICARE
U95435Medicare UPIN
205967OtherMEDICARE PROVIDER #
IL038009778Medicaid