Provider Demographics
NPI:1124155098
Name:CHIRO ONE WELLNESS CENTER OF CRYSTAL LAKE SC
Entity type:Organization
Organization Name:CHIRO ONE WELLNESS CENTER OF CRYSTAL LAKE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-468-1824
Mailing Address - Street 1:2625 BUTTERFIELD RD
Mailing Address - Street 2:STE 301N
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1234
Mailing Address - Country:US
Mailing Address - Phone:630-468-1824
Mailing Address - Fax:630-701-1007
Practice Address - Street 1:435 ANGELA LN STE 12
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-1074
Practice Address - Country:US
Practice Address - Phone:815-301-4200
Practice Address - Fax:815-301-4205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5632232OtherBCBS
IL215297Medicare PIN