Provider Demographics
NPI:1447372248
Name:RIDGEWELLNESS CENTER
Entity type:Organization
Organization Name:RIDGEWELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-256-9906
Mailing Address - Street 1:901 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1559
Mailing Address - Country:US
Mailing Address - Phone:847-256-9906
Mailing Address - Fax:
Practice Address - Street 1:901 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1559
Practice Address - Country:US
Practice Address - Phone:847-256-9906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38004576261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL12462Medicare ID - Type Unspecified