Provider Demographics
NPI:1194574020
Name:VILLAGE WELLNESS CENTER LLC VWC
Entity type:Organization
Organization Name:VILLAGE WELLNESS CENTER LLC VWC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-852-7454
Mailing Address - Street 1:2240 W OGDEN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4882
Mailing Address - Country:US
Mailing Address - Phone:312-399-9727
Mailing Address - Fax:
Practice Address - Street 1:2240 W OGDEN AVE STE 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4882
Practice Address - Country:US
Practice Address - Phone:312-399-9727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health