Provider Demographics
NPI:1972618569
Name:LAURA A WELLER DC PA
Entity Type:Organization
Organization Name:LAURA A WELLER DC PA
Other - Org Name:LAURA A WELLER DC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-894-7528
Mailing Address - Street 1:2090 MLK ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704
Mailing Address - Country:US
Mailing Address - Phone:727-894-7528
Mailing Address - Fax:727-823-6073
Practice Address - Street 1:2090 MLK ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704
Practice Address - Country:US
Practice Address - Phone:727-894-7528
Practice Address - Fax:727-823-6073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8030111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U81037Medicare UPIN
FL53871Medicare ID - Type Unspecified