Provider Demographics
NPI:1245574367
Name:ST. LOUIS OPTIMAL PERFORMANCE, LLC
Entity Type:Organization
Organization Name:ST. LOUIS OPTIMAL PERFORMANCE, LLC
Other - Org Name:OPTIMAL PERFORMANCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:LAIDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-778-9997
Mailing Address - Street 1:219 CHESTERFIELD TOWNE CTR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1257
Mailing Address - Country:US
Mailing Address - Phone:636-778-9997
Mailing Address - Fax:636-778-9994
Practice Address - Street 1:219 CHESTERFIELD TOWNE CTR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1257
Practice Address - Country:US
Practice Address - Phone:636-778-9997
Practice Address - Fax:636-778-9994
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. LOUIS OPTIMAL PERFORMANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-15
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012014238111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty