Provider Demographics
NPI:1487300935
Name:CROCKETT WELLNESS CLINIC LLC
Entity type:Organization
Organization Name:CROCKETT WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:331-888-6505
Mailing Address - Street 1:3075 BOOK RD UNIT 9155
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60567-1422
Mailing Address - Country:US
Mailing Address - Phone:630-454-1143
Mailing Address - Fax:
Practice Address - Street 1:2829 STONEWATER DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564
Practice Address - Country:US
Practice Address - Phone:630-454-1143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center