Healthcare Provider Details

I. General information

NPI: 1104014521
Provider Name (Legal Business Name): FAMILY WELLNESS CHIROPRACTIC, LCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 OZARK TRAIL DR STE 9 CLAYTON-CLARKSON CENTER
ELLISVILLE MO
63011-2164
US

IV. Provider business mailing address

355 OZARK TRAIL DR STE 9 CLAYTON-CLARKSON CENTER
ELLISVILLE MO
63011-2164
US

V. Phone/Fax

Practice location:
  • Phone: 636-527-5071
  • Fax:
Mailing address:
  • Phone: 636-527-5071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2005014052
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2005014052
License Number StateMO

VIII. Authorized Official

Name: DR. CARRIE ANN JARDINE
Title or Position: OWNER/MANAGER
Credential: DC
Phone: 636-527-5970