Provider Demographics
NPI:1417196288
Name:NORTH SHORE WELLNESS CENTER
Entity type:Organization
Organization Name:NORTH SHORE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-559-0680
Mailing Address - Street 1:606 ACADEMY DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2421
Mailing Address - Country:US
Mailing Address - Phone:847-559-0680
Mailing Address - Fax:847-559-0859
Practice Address - Street 1:606 ACADEMY DR
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2421
Practice Address - Country:US
Practice Address - Phone:847-559-0680
Practice Address - Fax:847-559-0859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
210054Medicare PIN