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General NPI Number Information
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NPI Number | 1629377650
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Entity Type | Organization
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Legal Business Name | ADVANCED WELLNESS CHIROPRACTIC AND FUNCTIONAL REHAB LLC
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Dates
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Enumeration Date | 03/16/2011
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Last Update Date | 03/16/2011
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Provider Practice Location Address
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Address Line | 231 E DELMAR RD
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City | ALTON
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State | IL
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Zip | 62002-5935
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Country | US
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Telephone | 618-462-6630
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Fax | 618-462-6640
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Provider Business Mailing Address
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Address Line | 231 E DELMAR RD
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City | ALTON
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State | IL
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Zip | 62002-5935
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Country | US
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Telephone | 618-462-6630
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Fax | 618-462-6640
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Authorized Official
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Title or Position | DOCTOR OF CHIROPRACTIC/ OWNER
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Name | DR. KYLE ANTHONY BUESTETON
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Credential | DC
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Telephone | 618-462-6630
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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 | 038.011560
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License Number State | IL
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