Provider Demographics
NPI:1225548290
Name:BRENTWOOD PAINSTOP LLC
Entity Type:Organization
Organization Name:BRENTWOOD PAINSTOP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-961-7181
Mailing Address - Street 1:8045 BIG BEND BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2714
Mailing Address - Country:US
Mailing Address - Phone:314-961-7181
Mailing Address - Fax:
Practice Address - Street 1:8045 BIG BEND BLVD STE 107
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2714
Practice Address - Country:US
Practice Address - Phone:314-961-7181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014010441171M00000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty