Provider Demographics
NPI:1265987804
Name:RUSTICI WELLNESS CENTER
Entity type:Organization
Organization Name:RUSTICI WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSTICI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-623-3001
Mailing Address - Street 1:3552 SW MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64082-2327
Mailing Address - Country:US
Mailing Address - Phone:816-623-3001
Mailing Address - Fax:
Practice Address - Street 1:3552 SW MARKET ST
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64082-2327
Practice Address - Country:US
Practice Address - Phone:816-623-3001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
483443Medicare UPIN