Provider Demographics
NPI:1235543158
Name:AEQUA HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:AEQUA HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-227-4442
Mailing Address - Street 1:179 CLARKSON EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2176
Mailing Address - Country:US
Mailing Address - Phone:636-227-4442
Mailing Address - Fax:
Practice Address - Street 1:179 CLARKSON EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2176
Practice Address - Country:US
Practice Address - Phone:636-227-4442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009030088111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty