Provider Demographics
NPI:1659495083
Name:WELLER, EDWARD JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JAMES
Last Name:WELLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15507 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3001
Mailing Address - Country:US
Mailing Address - Phone:636-527-3015
Mailing Address - Fax:636-527-3415
Practice Address - Street 1:15507 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-3001
Practice Address - Country:US
Practice Address - Phone:636-527-3015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007022344111N00000X
IL38009071111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor