Provider Demographics
NPI:1033586490
Name:C3 CHIROPRACTIC
Entity Type:Organization
Organization Name:C3 CHIROPRACTIC
Other - Org Name:FOUR RIVERS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPACTIC PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-239-1220
Mailing Address - Street 1:707 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-2709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2709
Practice Address - Country:US
Practice Address - Phone:636-239-1220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-01
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015001267111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA5962Medicare PIN