1205984770 NPI number — CHIRO ONE WELLNESS CENTER OF GLENVIEW CLINIC, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205984770 NPI number — CHIRO ONE WELLNESS CENTER OF GLENVIEW CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIRO ONE WELLNESS CENTER OF GLENVIEW CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205984770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2625 BUTTERFIELD RD
Provider Second Line Business Mailing Address:
SUITE 301N
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-468-1824
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 LEHIGH AVE
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
GLENVIEW
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60026-1691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-998-1199
Provider Business Practice Location Address Fax Number:
847-998-9617
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WANG
Authorized Official First Name:
SAM
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
630-468-1824

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1635339 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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