Provider Demographics
NPI:1104014521
Name:FAMILY WELLNESS CHIROPRACTIC, LCC
Entity Type:Organization
Organization Name:FAMILY WELLNESS CHIROPRACTIC, LCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JARDINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-527-5970
Mailing Address - Street 1:355 OZARK TRAIL DR STE 9
Mailing Address - Street 2:CLAYTON-CLARKSON CENTER
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2164
Mailing Address - Country:US
Mailing Address - Phone:636-527-5071
Mailing Address - Fax:
Practice Address - Street 1:355 OZARK TRAIL DR STE 9
Practice Address - Street 2:CLAYTON-CLARKSON CENTER
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2164
Practice Address - Country:US
Practice Address - Phone:636-527-5071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005014052111N00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1649471988OtherNPI