Provider Demographics
NPI:1063920916
Name:WELLNESS REVOLUTION LAKEVIEW LLC
Entity type:Organization
Organization Name:WELLNESS REVOLUTION LAKEVIEW LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BREITBACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-869-1773
Mailing Address - Street 1:3464 N LINCOLN AVE # G1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1173
Mailing Address - Country:US
Mailing Address - Phone:773-348-6908
Mailing Address - Fax:224-477-2617
Practice Address - Street 1:3464 N LINCOLN AVE # G1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-1173
Practice Address - Country:US
Practice Address - Phone:773-348-6908
Practice Address - Fax:224-477-2617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty