1487205530 NPI number — CHIROPRACTIC FAMILY WELLNESS CENTER LLC

Table of content: (NPI 1487205530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487205530 NPI number — CHIROPRACTIC FAMILY WELLNESS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROPRACTIC FAMILY WELLNESS CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHIROPRACTIC WELLNESS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487205530
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5427 HORNEMANN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63128-3228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-478-2117
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1747 SMIZER STATION RD STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63026-2784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-825-6555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WARREN
Authorized Official First Name:
BRITTANY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
314-478-2117

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1821333824 . This is a "CHIROPRACTOR" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".