Provider Demographics
NPI:1033177746
Name:EVERETT, EDGAR III (DC)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:
Last Name:EVERETT
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 WOODSON RD
Mailing Address - Street 2:STE #101
Mailing Address - City:OVERLAND
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5644
Mailing Address - Country:US
Mailing Address - Phone:314-713-1656
Mailing Address - Fax:314-395-0607
Practice Address - Street 1:2050 WOODSON RD
Practice Address - Street 2:STE #101
Practice Address - City:OVERLAND
Practice Address - State:MO
Practice Address - Zip Code:63114-5644
Practice Address - Country:US
Practice Address - Phone:314-713-1656
Practice Address - Fax:314-395-0607
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006022760111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200250OtherBCBS
MOMA1179001Medicare PIN
MO200250OtherBCBS