Provider Demographics
NPI:1053677187
Name:LAKE ZURICH WELLNESS GROUP
Entity type:Organization
Organization Name:LAKE ZURICH WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GLAUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-996-0007
Mailing Address - Street 1:28010 238TH ST
Mailing Address - Street 2:
Mailing Address - City:LE CLAIRE
Mailing Address - State:IA
Mailing Address - Zip Code:52753-9126
Mailing Address - Country:US
Mailing Address - Phone:847-996-0007
Mailing Address - Fax:847-996-0007
Practice Address - Street 1:165 S RAND RD
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2275
Practice Address - Country:US
Practice Address - Phone:847-550-4094
Practice Address - Fax:847-550-4096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty