Provider Demographics
NPI:1447389119
Name:EDSTROM, GREGORY WADE (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:WADE
Last Name:EDSTROM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5714 S LINDBERGH BLVD
Mailing Address - Street 2:#7
Mailing Address - City:AFFTON
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6955
Mailing Address - Country:US
Mailing Address - Phone:314-842-4929
Mailing Address - Fax:314-842-1829
Practice Address - Street 1:5714 S LINDBERGH BLVD
Practice Address - Street 2:#7
Practice Address - City:AFFTON
Practice Address - State:MO
Practice Address - Zip Code:63123-6955
Practice Address - Country:US
Practice Address - Phone:314-842-4929
Practice Address - Fax:314-842-1829
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO03699111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor