Healthcare Provider Details

I. General information

NPI: 1386852481
Provider Name (Legal Business Name): WILMINGTON CLINIC D.C., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4918 WEBER RD
SAINT LOUIS MO
63123-5645
US

IV. Provider business mailing address

4918 WEBER RD
SAINT LOUIS MO
63123-5645
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-1477
  • Fax: 314-631-3060
Mailing address:
  • Phone: 314-353-1477
  • Fax: 314-631-3060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number4167
License Number StateMO

VIII. Authorized Official

Name: DR. MICHAEL JOSEPH FISCELLA
Title or Position: PRESIDENT
Credential: D.C.
Phone: 314-353-1477