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General NPI Number Information
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NPI Number | 1376041665
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Entity Type | Organization
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Legal Business Name | ELITE CHIROPRACTIC OF THE OZARKS, LLC
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Dates
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Enumeration Date | 02/01/2018
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Last Update Date | 02/01/2018
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Provider Practice Location Address
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Address Line | 240 W MAIN ST
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City | WEST PLAINS
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State | MO
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Zip | 65775-2726
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Country | US
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Telephone | 417-257-2477
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 485
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City | BRANDSVILLE
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State | MO
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Zip | 65688-0485
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Country | US
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Telephone | 417-257-2477
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Fax |
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Authorized Official
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Title or Position | OWNER/ SOLE PHYSICIAN
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Name | DR. JOHNA WADE
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Credential | DC
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Telephone | 417-274-4366
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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 | 2018000970
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License Number State | MO
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