Provider Demographics
NPI:1164847513
Name:MAIN STREET WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:MAIN STREET WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DC
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'TOOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-343-7023
Mailing Address - Street 1:2101 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2159
Mailing Address - Country:US
Mailing Address - Phone:803-343-7023
Mailing Address - Fax:803-343-7043
Practice Address - Street 1:2101 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2159
Practice Address - Country:US
Practice Address - Phone:803-343-7023
Practice Address - Fax:803-343-7043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty