Provider Demographics
NPI:1962833095
Name:WEST CERMAK ROAD WELLNESS
Entity Type:Organization
Organization Name:WEST CERMAK ROAD WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MCKELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-863-1001
Mailing Address - Street 1:5623 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2220
Mailing Address - Country:US
Mailing Address - Phone:708-863-1001
Mailing Address - Fax:
Practice Address - Street 1:5623 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2220
Practice Address - Country:US
Practice Address - Phone:708-863-1001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012038111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty