Provider Demographics
NPI:1720473986
Name:CHIROPRACTIC WELLNESS CENTRE, PLLC
Entity Type:Organization
Organization Name:CHIROPRACTIC WELLNESS CENTRE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:662-470-4615
Mailing Address - Street 1:354 STATELINE RD W
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1610
Mailing Address - Country:US
Mailing Address - Phone:662-470-4615
Mailing Address - Fax:662-470-4619
Practice Address - Street 1:354 STATELINE RD W
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1610
Practice Address - Country:US
Practice Address - Phone:662-470-4615
Practice Address - Fax:662-470-4619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1234305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service