Provider Demographics
NPI:1023594181
Name:WELLNESS COLLECTIVE CHICAGO, LLC
Entity type:Organization
Organization Name:WELLNESS COLLECTIVE CHICAGO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:630-254-0817
Mailing Address - Street 1:420 W HURON ST STE 231
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-8475
Mailing Address - Country:US
Mailing Address - Phone:773-706-8295
Mailing Address - Fax:
Practice Address - Street 1:420 W HURON ST STE 231
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-8475
Practice Address - Country:US
Practice Address - Phone:773-706-8295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038013230261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center