Provider Demographics
NPI:1619483294
Name:HERITAGE WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:HERITAGE WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRED. SPEC.
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-277-9927
Mailing Address - Street 1:2730 S SAINT PETERS PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63303-5677
Mailing Address - Country:US
Mailing Address - Phone:636-277-9927
Mailing Address - Fax:636-295-4741
Practice Address - Street 1:2730 S SAINT PETERS PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63303-5677
Practice Address - Country:US
Practice Address - Phone:636-277-9927
Practice Address - Fax:636-295-4741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty