1942574959 NPI number — UNIVERSAL WELLNESS SOURCE AT LAKESHORE EAST SC

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 1942574959 NPI number — UNIVERSAL WELLNESS SOURCE AT LAKESHORE EAST SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSAL WELLNESS SOURCE AT LAKESHORE EAST SC
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:
1942574959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5501 S 208TH CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKHORN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68022-3138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-578-5133
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 E BENTON PL
Provider Second Line Business Practice Location Address:
104
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60601-7412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-578-5133
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GASIOROWSKI
Authorized Official First Name:
KAYLYNNE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT/OWNER/CHIROPRACTIC DOCTOR
Authorized Official Telephone Number:
402-578-5133

Provider Taxonomy Codes

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

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





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