Provider Demographics
NPI:1386852481
Name:WILMINGTON CLINIC D.C., P.C.
Entity Type:Organization
Organization Name:WILMINGTON CLINIC D.C., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FISCELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-353-1477
Mailing Address - Street 1:4918 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-5645
Mailing Address - Country:US
Mailing Address - Phone:314-353-1477
Mailing Address - Fax:314-631-3060
Practice Address - Street 1:4918 WEBER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-5645
Practice Address - Country:US
Practice Address - Phone:314-353-1477
Practice Address - Fax:314-631-3060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4167111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT43345Medicare UPIN