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General NPI Number Information
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NPI Number | 1023524097
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Entity Type | Organization
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Legal Business Name | COMPLETE FAMILY CHIROPRACTIC & WELLNESS LLC
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Dates
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Enumeration Date | 12/28/2017
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Last Update Date | 12/28/2017
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Provider Practice Location Address
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Address Line | 317 MARKETPLACE DR
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City | FREEBURG
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State | IL
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Zip | 62243-4075
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Country | US
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Telephone | 618-710-5004
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Fax |
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Provider Business Mailing Address
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Address Line | 19 LEO DR
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City | FAIRVIEW HEIGHTS
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State | IL
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Zip | 62208-1908
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Country | US
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Telephone | 618-443-8374
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. SAMANTHA GLASCO
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Credential | DC
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Telephone | 618-710-5004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 038012820
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License Number State | IL
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