Provider Demographics
NPI:1043404114
Name:CRIDER CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:CRIDER CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:STALCUP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-315-2868
Mailing Address - Street 1:1043A WOLFRUM RD
Mailing Address - Street 2:
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-7625
Mailing Address - Country:US
Mailing Address - Phone:314-315-2868
Mailing Address - Fax:
Practice Address - Street 1:1043A WOLFRUM RD
Practice Address - Street 2:
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-7625
Practice Address - Country:US
Practice Address - Phone:314-315-2868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007021516302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization