Provider Demographics
NPI:1124194428
Name:PROFICIENT CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:PROFICIENT CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:314-713-1656
Mailing Address - Street 1:2050 WOODSON RD
Mailing Address - Street 2:STE #101
Mailing Address - City:SAINT LOUIS
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:SAINT LOUIS
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006022760111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200250OtherBCBS
MOV04028Medicare UPIN
MOMA1179Medicare PIN