Provider Demographics
NPI:1225214893
Name:WESTPORT CHIROPRACTIC AND WELLNESS LLC
Entity Type:Organization
Organization Name:WESTPORT CHIROPRACTIC AND WELLNESS LLC
Other - Org Name:WELLPRO CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-985-0815
Mailing Address - Street 1:2060 CONCOURSE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4119
Mailing Address - Country:US
Mailing Address - Phone:314-985-0815
Mailing Address - Fax:314-985-0819
Practice Address - Street 1:2060 CONCOURSE DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4119
Practice Address - Country:US
Practice Address - Phone:314-985-0815
Practice Address - Fax:314-985-0819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007029226111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty