Provider Demographics
NPI:1982035440
Name:EZELL CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:EZELL CHIROPRACTIC LLC
Other - Org Name:EZELL CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:EZELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-916-0660
Mailing Address - Street 1:2201 1ST CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-5805
Mailing Address - Country:US
Mailing Address - Phone:636-916-0660
Mailing Address - Fax:
Practice Address - Street 1:2201 1ST CAPITOL DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-5805
Practice Address - Country:US
Practice Address - Phone:636-916-0660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013000467261Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center