Provider Demographics
NPI:1275771669
Name:WELLNESS CONCEPTS CLINIC LLC
Entity Type:Organization
Organization Name:WELLNESS CONCEPTS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:REAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-877-1300
Mailing Address - Street 1:1200 E WOODHURST DR
Mailing Address - Street 2:STE R 300
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4261
Mailing Address - Country:US
Mailing Address - Phone:417-877-1300
Mailing Address - Fax:417-877-1335
Practice Address - Street 1:1200 E WOODHURST DR
Practice Address - Street 2:STE R 300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4261
Practice Address - Country:US
Practice Address - Phone:417-877-1300
Practice Address - Fax:417-877-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003027886111N00000X
MO2007008411111NS0005X
MO2002030343171100000X
MO2002024850171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1366648560Medicare UPIN
MO000026109Medicare UPIN