Provider Demographics
NPI:1275987646
Name:ST. E CHIROPRACTIC AND REHAB, LLC
Entity Type:Organization
Organization Name:ST. E CHIROPRACTIC AND REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:937-974-8879
Mailing Address - Street 1:1 ELIZABETH PL
Mailing Address - Street 2:SUITE 280
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3445
Mailing Address - Country:US
Mailing Address - Phone:937-974-8879
Mailing Address - Fax:937-660-4066
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:SUITE 280
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3445
Practice Address - Country:US
Practice Address - Phone:937-974-8879
Practice Address - Fax:937-660-4066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-21
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty