=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629393087
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROOTS OF WELLNESS CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2010
-----------------------------------------------------
Last Update Date | 03/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 BAXTER RD SUITE 8
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-7032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-227-4442
-----------------------------------------------------
Fax | 636-227-4449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 510 BAXTER RD SUITE 8
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-7032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-227-4442
-----------------------------------------------------
Fax | 636-227-4449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DANIEL FAZIO
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 636-227-4442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2009030088
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------