Provider Demographics
NPI:1508248311
Name:PREMIER CHIROPRACTIC WELLNESS CENTRE
Entity Type:Organization
Organization Name:PREMIER CHIROPRACTIC WELLNESS CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-691-5404
Mailing Address - Street 1:9 THE PLZ
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1365
Mailing Address - Country:US
Mailing Address - Phone:314-691-5404
Mailing Address - Fax:
Practice Address - Street 1:9 THE PLZ
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1365
Practice Address - Country:US
Practice Address - Phone:314-691-5404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015020087111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA5685OtherMEDICARE PTAN