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General NPI Number Information
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NPI Number | 1235543158
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Entity Type | Organization
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Legal Business Name | AEQUA HEALTH AND WELLNESS LLC
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Dates
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Enumeration Date | 06/18/2014
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Last Update Date | 06/18/2014
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Provider Practice Location Address
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Address Line | 179 CLARKSON EXECUTIVE PARK
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City | ELLISVILLE
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State | MO
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Zip | 63011-2176
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Country | US
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Telephone | 636-227-4442
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Fax |
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Provider Business Mailing Address
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Address Line | 179 CLARKSON EXECUTIVE PARK
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City | ELLISVILLE
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State | MO
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Zip | 63011-2176
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Country | US
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Telephone | 636-227-4442
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DANIEL MICHAEL FAZIO
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Credential | DC
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Telephone | 636-227-4442
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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 | 2009030088
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License Number State | MO
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