Provider Demographics
NPI:1144388315
Name:OLDE TOWNE WELLNESS LLC
Entity Type:Organization
Organization Name:OLDE TOWNE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMNAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HENNESSEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:804-733-8377
Mailing Address - Street 1:515 S SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-5037
Mailing Address - Country:US
Mailing Address - Phone:804-733-8377
Mailing Address - Fax:804-733-8459
Practice Address - Street 1:515 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-5037
Practice Address - Country:US
Practice Address - Phone:804-733-8377
Practice Address - Fax:804-733-8459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001801111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA418235OtherSOUTHERN HEALTH
VA191798OtherANTHEM
VA640-504OtherUNITED HEATH CARE
190000999Medicare ID - Type Unspecified
VA191798OtherANTHEM