Provider Demographics
NPI:1538288048
Name:CHIROPRACTIC ACCIDENT CENTER OF FENTON, P.C.
Entity Type:Organization
Organization Name:CHIROPRACTIC ACCIDENT CENTER OF FENTON, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESA
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-343-9595
Mailing Address - Street 1:408 GRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-4133
Mailing Address - Country:US
Mailing Address - Phone:636-343-9595
Mailing Address - Fax:636-343-8126
Practice Address - Street 1:408 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-4133
Practice Address - Country:US
Practice Address - Phone:636-343-9595
Practice Address - Fax:636-343-8126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005984111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO17425OtherANTHEM BLUE CROSS BLUE SH
MO32132Medicare ID - Type Unspecified