Provider Demographics
NPI:1952657991
Name:CALLISTA C LAY LTD
Entity Type:Organization
Organization Name:CALLISTA C LAY LTD
Other - Org Name:GENESIS CHIROPRACTIC WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CALLISTA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-491-8100
Mailing Address - Street 1:917 W WASHINGTON BLVD BOX 254
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607
Mailing Address - Country:US
Mailing Address - Phone:312-491-8100
Mailing Address - Fax:312-491-8105
Practice Address - Street 1:1169 W MADISON
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607
Practice Address - Country:US
Practice Address - Phone:312-491-8100
Practice Address - Fax:312-491-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty