Provider Demographics
NPI:1366785420
Name:360 WELLNESS LLC
Entity type:Organization
Organization Name:360 WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:573-694-5162
Mailing Address - Street 1:925 S COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-4510
Mailing Address - Country:US
Mailing Address - Phone:573-694-5162
Mailing Address - Fax:573-583-3444
Practice Address - Street 1:925 S COUNTRY CLUB DR
Practice Address - Street 2:SUITE 3
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-4510
Practice Address - Country:US
Practice Address - Phone:573-694-5162
Practice Address - Fax:573-583-3444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012026052111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1669728408Medicare PIN