Provider Demographics
NPI:1649553132
Name:WILDWOOD HEALTH & WELLNESS CENTER, P.C.
Entity type:Organization
Organization Name:WILDWOOD HEALTH & WELLNESS CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:VAN HORENBEECT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-458-7787
Mailing Address - Street 1:16917 MANCHESTER RD.
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1209
Mailing Address - Country:US
Mailing Address - Phone:636-458-7787
Mailing Address - Fax:636-458-0911
Practice Address - Street 1:16917 MANCHESTER RD.
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1209
Practice Address - Country:US
Practice Address - Phone:636-458-7787
Practice Address - Fax:636-458-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006210111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000031468Medicare UPIN