Basic Information
| Provider Information | |||||||||
| NPI: | 1073607016 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOLD COAST WELLNESS CENTER LTD. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | GOLD COAST WELLNESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1360 N SANDBURG TER | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606102075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129444653 | ||||||||
| FaxNumber: | 3129440747 | ||||||||
| Practice Location | |||||||||
| Address1: | 1360 N SANDBURG TER | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606102075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129444653 | ||||||||
| FaxNumber: | 3129440747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ODISHO | ||||||||
| AuthorizedOfficialFirstName: | SARGON | ||||||||
| AuthorizedOfficialMiddleName: | BENJAMIN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3129444653 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.C. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.