1215342829 NPI number — ILLINOIS WELLNESS GROUP OF JOLIET, LTD

Table of content: (NPI 1215342829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215342829 NPI number — ILLINOIS WELLNESS GROUP OF JOLIET, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS WELLNESS GROUP OF JOLIET, LTD
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:
1215342829
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 N LARKIN AVE
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
JOLIET
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60435-3438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-714-2271
Provider Business Mailing Address Fax Number:
815-582-3262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 N LARKIN AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
JOLIET
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60435-3438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-714-2271
Provider Business Practice Location Address Fax Number:
815-582-3262
Provider Enumeration Date:
06/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
NASH
Authorized Official First Name:
BRETT
Authorized Official Middle Name:
NOLAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-714-2271

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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