Provider Demographics
NPI:1326362112
Name:ST. LOUIS CENTER FOR FUNCTIONAL MEDICINE, LLC
Entity Type:Organization
Organization Name:ST. LOUIS CENTER FOR FUNCTIONAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:NEUWIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-394-0636
Mailing Address - Street 1:1054 OLD DES PERES RD
Mailing Address - Street 2:
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1865
Mailing Address - Country:US
Mailing Address - Phone:314-394-0636
Mailing Address - Fax:314-394-1021
Practice Address - Street 1:1054 OLD DES PERES RD
Practice Address - Street 2:
Practice Address - City:DES PERES
Practice Address - State:MO
Practice Address - Zip Code:63131-1865
Practice Address - Country:US
Practice Address - Phone:314-394-0636
Practice Address - Fax:314-394-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006776111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty