Provider Demographics
NPI:1427392356
Name:SPINE AND JOINT CARE OF FENTON, LLC
Entity Type:Organization
Organization Name:SPINE AND JOINT CARE OF FENTON, LLC
Other - Org Name:SPINE AND JOINT CENTER OF AFFTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:ANGELA
Authorized Official - Last Name:SPATH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-353-4500
Mailing Address - Street 1:8005 MACKENZIE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-3518
Mailing Address - Country:US
Mailing Address - Phone:314-353-4500
Mailing Address - Fax:314-353-4502
Practice Address - Street 1:8005 MACKENZIE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-3518
Practice Address - Country:US
Practice Address - Phone:314-353-4500
Practice Address - Fax:314-353-4502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008027067111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty