Provider Demographics
NPI:1912178260
Name:ADVANCED WELLNESS CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:ADVANCED WELLNESS CHIROPRACTIC, PLLC
Other - Org Name:BROCKMAN CHIROPRACTIC AND WELLNESS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:270-927-1000
Mailing Address - Street 1:135 MAIN CROSS STREET
Mailing Address - Street 2:PO BOX 242
Mailing Address - City:HAWESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 MAIN CROSS STREET
Practice Address - Street 2:
Practice Address - City:HAWESVILLE
Practice Address - State:KY
Practice Address - Zip Code:42348
Practice Address - Country:US
Practice Address - Phone:270-927-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5101111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty