Provider Demographics
NPI:1477014553
Name:CHIRO ONE WELLNESS CENTER OF O'FALLON ILLINOIS LLC
Entity Type:Organization
Organization Name:CHIRO ONE WELLNESS CENTER OF O'FALLON ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-229-4430
Mailing Address - Street 1:2625 BUTTERFIELD RD STE 301N
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1266
Mailing Address - Country:US
Mailing Address - Phone:630-468-1824
Mailing Address - Fax:
Practice Address - Street 1:1411 W HIGHWAY 50 STE 103
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1618
Practice Address - Country:US
Practice Address - Phone:630-468-1824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-29
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty