Provider Demographics
NPI:1629393087
Name:ROOTS OF WELLNESS CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:ROOTS OF WELLNESS CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-227-4442
Mailing Address - Street 1:510 BAXTER RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7032
Mailing Address - Country:US
Mailing Address - Phone:636-227-4442
Mailing Address - Fax:636-227-4449
Practice Address - Street 1:510 BAXTER RD
Practice Address - Street 2:SUITE 8
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-7032
Practice Address - Country:US
Practice Address - Phone:636-227-4442
Practice Address - Fax:636-227-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009030088111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty