Provider Demographics
NPI:1508158445
Name:CHIROPRACTIC WELLNESS CENTER OF ST LOUIS LLC
Entity Type:Organization
Organization Name:CHIROPRACTIC WELLNESS CENTER OF ST LOUIS LLC
Other - Org Name:CHIROPRACTIC WELLNESS CENTER OF SOUTH COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORENELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOFQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-825-6555
Mailing Address - Street 1:1747 SMIZER STATION RD
Mailing Address - Street 2:STE. 4
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2784
Mailing Address - Country:US
Mailing Address - Phone:636-825-6555
Mailing Address - Fax:636-825-6546
Practice Address - Street 1:1747 SMIZER STATION RD
Practice Address - Street 2:STE. 4
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2784
Practice Address - Country:US
Practice Address - Phone:636-825-6555
Practice Address - Fax:636-825-6546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011012193261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service