Provider Demographics
NPI:1003856832
Name:PRIMARY CARE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:PRIMARY CARE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARQUART
Authorized Official - Suffix:
Authorized Official - Credentials:DC DACBR
Authorized Official - Phone:636-227-4151
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63011-1100
Mailing Address - Country:US
Mailing Address - Phone:636-227-4151
Mailing Address - Fax:
Practice Address - Street 1:201 ENCHANTED PKWY
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-5493
Practice Address - Country:US
Practice Address - Phone:636-227-4151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004979111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013934Medicare ID - Type UnspecifiedMC GROUP