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General NPI Number Information
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NPI Number | 1861901761
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Entity Type | Organization
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Legal Business Name | ADVANCED WELLNESS CHIROPRACTIC LLC
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Dates
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Enumeration Date | 09/22/2017
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Last Update Date | 07/14/2023
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Provider Practice Location Address
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Address Line | 7612 S SUNSET DR
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City | SAINT LOUIS
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State | MO
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Zip | 63121-2430
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Country | US
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Telephone | 314-393-5391
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Fax |
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Provider Business Mailing Address
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Address Line | 7612 S. SUNSET DRIVE
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City | SAINT LOUIS
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State | MO
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Zip | 63121-7352
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Country | US
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Telephone | 314-393-6139
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JE'AN-CLAUDE DALTON BORDEAUX
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Credential | DC
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Telephone | 636-206-6004
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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 |
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License Number State |
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