Provider Demographics
NPI:1235164542
Name:ST JOHN CHIROPRACTIC OFFICE PC
Entity Type:Organization
Organization Name:ST JOHN CHIROPRACTIC OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:ST JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-967-2470
Mailing Address - Street 1:301 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483-1621
Mailing Address - Country:US
Mailing Address - Phone:417-967-2470
Mailing Address - Fax:417-967-3962
Practice Address - Street 1:301 S 1ST ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-1621
Practice Address - Country:US
Practice Address - Phone:417-967-2470
Practice Address - Fax:417-967-3962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO3368111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T43076OtherUPIN