Provider Demographics
NPI:1912125485
Name:WELLNESSONE OF EAST BELLEVILLE, LLC
Entity Type:Organization
Organization Name:WELLNESSONE OF EAST BELLEVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:M
Authorized Official - Last Name:DORRITY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-398-9716
Mailing Address - Street 1:1634 CARLYLE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-4558
Mailing Address - Country:US
Mailing Address - Phone:618-235-0777
Mailing Address - Fax:618-235-9440
Practice Address - Street 1:1634 CARLYLE AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-4558
Practice Address - Country:US
Practice Address - Phone:618-235-0777
Practice Address - Fax:618-235-9440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08212176OtherBCBS GROUP NUMBER
IL212900Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER