Provider Demographics
NPI:1336357854
Name:FAMILY WELLNESS CARE
Entity Type:Organization
Organization Name:FAMILY WELLNESS CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKENLOOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-854-8052
Mailing Address - Street 1:1451 MERCHANT DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5917
Mailing Address - Country:US
Mailing Address - Phone:847-854-8052
Mailing Address - Fax:847-854-6706
Practice Address - Street 1:1451 MERCHANT DR
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5917
Practice Address - Country:US
Practice Address - Phone:847-854-8052
Practice Address - Fax:847-854-6706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2008-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NI0900X, 111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
No111NI0900XChiropractic ProvidersChiropractorInternistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4529988OtherBLUE CROSS BLUE SHIELD
IL211284Medicare ID - Type Unspecified