Provider Demographics
NPI:1760501696
Name:WELLNESS CHIROPRACTIC
Entity type:Organization
Organization Name:WELLNESS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:502-776-7090
Mailing Address - Street 1:2623 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-1332
Mailing Address - Country:US
Mailing Address - Phone:502-776-7090
Mailing Address - Fax:502-776-8922
Practice Address - Street 1:2623 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1332
Practice Address - Country:US
Practice Address - Phone:502-776-7090
Practice Address - Fax:502-776-8922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4418111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6086801Medicare ID - Type Unspecified
KYU78817Medicare UPIN