Healthcare Provider Details

I. General information

NPI: 1699924373
Provider Name (Legal Business Name): MARVEL CHIROPRACTIC AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 E BROADWAY BLVD
JOHNSTON CITY IL
62951-1608
US

IV. Provider business mailing address

417 E BROADWAY BLVD
JOHNSTON CITY IL
62951-1608
US

V. Phone/Fax

Practice location:
  • Phone: 618-983-8100
  • Fax: 618-983-8110
Mailing address:
  • Phone: 618-983-8100
  • Fax: 618-983-8110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.011177
License Number StateIL

VIII. Authorized Official

Name: DR. MICHELLE D. MARVEL
Title or Position: MANAGER
Credential: D.C.
Phone: 618-983-8100