Healthcare Provider Details

I. General information

NPI: 1861901761
Provider Name (Legal Business Name): ADVANCED WELLNESS CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2017
Last Update Date: 03/21/2026
Certification Date: 03/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11520 SAINT CHARLES ROCK RD STE 104
BRIDGETON MO
63044-2732
US

IV. Provider business mailing address

11520 SAINT CHARLES ROCK RD STE 104
BRIDGETON MO
63044-2732
US

V. Phone/Fax

Practice location:
  • Phone: 314-393-5391
  • Fax:
Mailing address:
  • Phone: 314-393-5391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JE'AN-CLAUDE DALTON BORDEAUX
Title or Position: OWNER
Credential: DC
Phone: 314-393-5391