1255813770 NPI number — GALESBURG WELLNESS SYSTEMS P.C.

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 1255813770 NPI number — GALESBURG WELLNESS SYSTEMS P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GALESBURG WELLNESS SYSTEMS P.C.
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:
6
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:
1255813770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2377 CUMBERLAND SQUARE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BETTENDORF
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52722-3251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-359-9541
Provider Business Mailing Address Fax Number:
563-344-3914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
575 N KELLOGG ST STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALESBURG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61401-7609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-344-4778
Provider Business Practice Location Address Fax Number:
563-344-3914
Provider Enumeration Date:
08/31/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MARLOWE
Authorized Official First Name:
JODI
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCOUNTS ADMINISTRATOR
Authorized Official Telephone Number:
563-359-9541

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)





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