Provider Demographics
NPI:1942574959
Name:UNIVERSAL WELLNESS SOURCE AT LAKESHORE EAST SC
Entity type:Organization
Organization Name:UNIVERSAL WELLNESS SOURCE AT LAKESHORE EAST SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER/CHIROPRACTIC DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAYLYNNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GASIOROWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:402-578-5133
Mailing Address - Street 1:5501 S 208TH CIR
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-3138
Mailing Address - Country:US
Mailing Address - Phone:402-578-5133
Mailing Address - Fax:
Practice Address - Street 1:333 E BENTON PL
Practice Address - Street 2:104
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7412
Practice Address - Country:US
Practice Address - Phone:402-578-5133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty