Provider Demographics
NPI:1700089430
Name:SOUTHPORT GRACE WELLNESS CENTER LTD.
Entity Type:Organization
Organization Name:SOUTHPORT GRACE WELLNESS CENTER LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:C
Authorized Official - Last Name:WOLCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-525-2225
Mailing Address - Street 1:1209 W. GRACE ST.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613
Mailing Address - Country:US
Mailing Address - Phone:773-525-2225
Mailing Address - Fax:
Practice Address - Street 1:1209 W. GRACE ST.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613
Practice Address - Country:US
Practice Address - Phone:773-525-2225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208229Medicare ID - Type Unspecified