Provider Demographics
NPI:1588941702
Name:WELLNESS CHIROPRACTIC CENTER PC
Entity type:Organization
Organization Name:WELLNESS CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:W
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-296-4000
Mailing Address - Street 1:2090 ELM DR
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-4192
Mailing Address - Country:US
Mailing Address - Phone:636-296-4000
Mailing Address - Fax:636-282-8530
Practice Address - Street 1:2090 ELM DR
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-4192
Practice Address - Country:US
Practice Address - Phone:636-296-4000
Practice Address - Fax:636-282-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006005302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU43461Medicare UPIN