Provider Demographics
NPI:1104610286
Name:WICKED WELLNESS SPA PLLC
Entity type:Organization
Organization Name:WICKED WELLNESS SPA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLIA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:BOLLS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:708-600-2005
Mailing Address - Street 1:6700 167TH ST STE 4&5
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2859
Mailing Address - Country:US
Mailing Address - Phone:708-781-3007
Mailing Address - Fax:708-600-2005
Practice Address - Street 1:6700 167TH ST STE 4&5
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2859
Practice Address - Country:US
Practice Address - Phone:708-781-3007
Practice Address - Fax:708-600-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-05
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty