Provider Demographics
NPI:1518161744
Name:CHIROPRACTIC AND WELLNESS CENTER, PC
Entity Type:Organization
Organization Name:CHIROPRACTIC AND WELLNESS CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-580-9867
Mailing Address - Street 1:1305 W 96TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1192
Mailing Address - Country:US
Mailing Address - Phone:317-580-9867
Mailing Address - Fax:317-581-0209
Practice Address - Street 1:1305 W 96TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1192
Practice Address - Country:US
Practice Address - Phone:317-580-9867
Practice Address - Fax:317-581-0209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN263830Medicare PIN