Provider Demographics
NPI:1740661941
Name:WELLNESS INSTITUTE OF ILLINOIS, LTD.
Entity type:Organization
Organization Name:WELLNESS INSTITUTE OF ILLINOIS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-477-8844
Mailing Address - Street 1:741 S MCHENRY AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7445
Mailing Address - Country:US
Mailing Address - Phone:815-477-8844
Mailing Address - Fax:815-308-3387
Practice Address - Street 1:110 W HILLCREST BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60195-3105
Practice Address - Country:US
Practice Address - Phone:815-687-6735
Practice Address - Fax:815-308-3387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-12
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36.0422751261Q00000X
IL036-049364261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center