Provider Demographics
NPI:1316420763
Name:WEST SUBURBAN WELLNESS OF OAK BROOK, LLC.
Entity type:Organization
Organization Name:WEST SUBURBAN WELLNESS OF OAK BROOK, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WESELAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-629-9500
Mailing Address - Street 1:1100 JORIE BLVD STE 318
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 JORIE BLVD STE 318
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2242
Practice Address - Country:US
Practice Address - Phone:630-629-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-12
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00416153OtherRAILROAD MEDICARE
IL0002232693OtherBCBS