Provider Demographics
NPI:1073805776
Name:WELLNESS CONCEPTS CLINIC
Entity Type:Organization
Organization Name:WELLNESS CONCEPTS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:REAVIS-ALEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-877-1300
Mailing Address - Street 1:1200 E WOODHURST DR
Mailing Address - Street 2:SUITE R300
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:417-877-1335
Practice Address - Street 1:1200 E WOODHURST DR
Practice Address - Street 2:SUITE R300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4261
Practice Address - Country:US
Practice Address - Phone:417-877-1300
Practice Address - Fax:417-877-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007008411111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2002030343OtherLICENSE
MO2010000775OtherLICENSE
MO2010000775OtherLICENSE
MO2003027886Medicare UPIN