Provider Demographics
NPI:1205138120
Name:CHIROPRACTIC OF WILDWOOD, LLC
Entity type:Organization
Organization Name:CHIROPRACTIC OF WILDWOOD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:TAL
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-495-4928
Mailing Address - Street 1:2476 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1222
Mailing Address - Country:US
Mailing Address - Phone:636-458-7575
Mailing Address - Fax:636-458-7979
Practice Address - Street 1:2476 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1222
Practice Address - Country:US
Practice Address - Phone:636-458-7575
Practice Address - Fax:636-458-7979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002014997111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty