Provider Demographics
NPI:1699924373
Name:MARVEL CHIROPRACTIC AND WELLNESS CENTER LLC
Entity type:Organization
Organization Name:MARVEL CHIROPRACTIC AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARVEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-983-8100
Mailing Address - Street 1:417 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62951-1608
Mailing Address - Country:US
Mailing Address - Phone:618-983-8100
Mailing Address - Fax:618-983-8110
Practice Address - Street 1:417 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:JOHNSTON CITY
Practice Address - State:IL
Practice Address - Zip Code:62951-1608
Practice Address - Country:US
Practice Address - Phone:618-983-8100
Practice Address - Fax:618-983-8110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011177111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty