Healthcare Provider Details

I. General information

NPI: 1518161744
Provider Name (Legal Business Name): CHIROPRACTIC AND WELLNESS CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 W 96TH ST SUITE C
INDIANAPOLIS IN
46260-1192
US

IV. Provider business mailing address

1305 W 96TH ST SUITE C
INDIANAPOLIS IN
46260-1192
US

V. Phone/Fax

Practice location:
  • Phone: 317-580-9867
  • Fax: 317-581-0209
Mailing address:
  • Phone: 317-580-9867
  • Fax: 317-581-0209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIN

VIII. Authorized Official

Name: DR. MARY JO JOHNSON
Title or Position: OWNER
Credential: D.C.
Phone: 317-580-9867