Provider Demographics
NPI:1346271822
Name:BOUCK, SR., DOUGLAS (DC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:BOUCK, SR.
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11705 GRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1803
Mailing Address - Country:US
Mailing Address - Phone:314-843-4636
Mailing Address - Fax:
Practice Address - Street 1:11705 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1803
Practice Address - Country:US
Practice Address - Phone:314-843-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004788111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000030957Medicare PIN
MOT43432Medicare UPIN