Provider Demographics
NPI:1609043298
Name:BACK & NECK CARE CENTER OF WEBSTER GROVES, LLC
Entity Type:Organization
Organization Name:BACK & NECK CARE CENTER OF WEBSTER GROVES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:T
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-968-4696
Mailing Address - Street 1:604 E LOCKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-3219
Mailing Address - Country:US
Mailing Address - Phone:314-968-4696
Mailing Address - Fax:314-968-0484
Practice Address - Street 1:604 E LOCKWOOD AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-3219
Practice Address - Country:US
Practice Address - Phone:314-968-4696
Practice Address - Fax:314-968-0484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCE004876111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO9360OtherBLUE CROSS BLUE SHIELD
MO2027274OtherAETNA
MO625709OtherACN
MO4401192OtherUNITED HEALTH CARE
MO114153OtherHEATLTH LINK
MO000030135Medicare PIN