Healthcare Provider Details

I. General information

NPI: 1104124619
Provider Name (Legal Business Name): ABUNDANT LIFE CHIROPRACTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 03/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 WOLFRUM RD
WELDON SPRING MO
63304-7795
US

IV. Provider business mailing address

1090 WOLFRUM RD
WELDON SPRING MO
63304-7795
US

V. Phone/Fax

Practice location:
  • Phone: 636-447-8600
  • Fax: 636-447-8842
Mailing address:
  • Phone: 636-447-8600
  • Fax: 636-447-8842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2002032305
License Number StateMO

VIII. Authorized Official

Name: DR. BRANDON R MAXWELL
Title or Position: OWNER
Credential: D.C.
Phone: 636-447-8600