1639333016 NPI number — VWELL WEST, INC.

Table of content: (NPI 1639333016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639333016 NPI number — VWELL WEST, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VWELL WEST, INC.
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:
1639333016
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 HOWARD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60202-3735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-258-9355
Provider Business Mailing Address Fax Number:
630-369-6984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 BOND ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-258-9355
Provider Business Practice Location Address Fax Number:
630-369-6984
Provider Enumeration Date:
07/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROSALES
Authorized Official First Name:
ALLAN
Authorized Official Middle Name:
DENNIS
Authorized Official Title or Position:
CLINICAL OPERATIONS EXECUTIVE
Authorized Official Telephone Number:
312-989-9260

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HHA4404 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 147806 . This is a "MEDICARE PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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