Provider Demographics
NPI:1770818759
Name:WELLNESS MANAGEMENT CHIROPRACTIC & MEDICAL CLINIC INC.
Entity Type:Organization
Organization Name:WELLNESS MANAGEMENT CHIROPRACTIC & MEDICAL CLINIC INC.
Other - Org Name:THORNELL MITCHELL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:KENNISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-433-1919
Mailing Address - Street 1:2121 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7103
Mailing Address - Country:US
Mailing Address - Phone:337-433-1919
Mailing Address - Fax:337-433-1928
Practice Address - Street 1:2121 LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7103
Practice Address - Country:US
Practice Address - Phone:337-433-1919
Practice Address - Fax:337-433-1928
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1137261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAU70741Medicare UPIN