Provider Demographics
NPI:1457885170
Name:MOBILE CHIROPRACTIC AND WELLNESS PLLC
Entity Type:Organization
Organization Name:MOBILE CHIROPRACTIC AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILLAINE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:ST.MICHEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-570-9388
Mailing Address - Street 1:3784 N CHOCAYA PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6075
Mailing Address - Country:US
Mailing Address - Phone:208-570-9388
Mailing Address - Fax:
Practice Address - Street 1:3784 N CHOCAYA PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6075
Practice Address - Country:US
Practice Address - Phone:208-570-9388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1661111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty