Provider Demographics
NPI:1790391738
Name:KMO WELLNESS 1, LLC
Entity Type:Organization
Organization Name:KMO WELLNESS 1, LLC
Other - Org Name:MODERN ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FRANCHISE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERPOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-376-8737
Mailing Address - Street 1:12133 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-4310
Mailing Address - Country:US
Mailing Address - Phone:605-376-8737
Mailing Address - Fax:
Practice Address - Street 1:12133 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:DES PERES
Practice Address - State:MO
Practice Address - Zip Code:63131-4310
Practice Address - Country:US
Practice Address - Phone:605-376-8737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-16
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty