Provider Demographics
NPI:1225283633
Name:CHIROPRACTIC HEALTH AND WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:CHIROPRACTIC HEALTH AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-326-8010
Mailing Address - Street 1:PO BOX 198
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-0198
Mailing Address - Country:US
Mailing Address - Phone:417-326-8010
Mailing Address - Fax:417-326-8011
Practice Address - Street 1:495 S MAIN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2126
Practice Address - Country:US
Practice Address - Phone:417-326-8010
Practice Address - Fax:417-326-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty