Provider Demographics
NPI:1154860435
Name:MARANATHA HEALTH AND WELLNESS CENTRE, LLC
Entity Type:Organization
Organization Name:MARANATHA HEALTH AND WELLNESS CENTRE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-679-0404
Mailing Address - Street 1:333 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65655
Mailing Address - Country:US
Mailing Address - Phone:417-679-0404
Mailing Address - Fax:
Practice Address - Street 1:333 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65655
Practice Address - Country:US
Practice Address - Phone:417-679-0404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty