Provider Demographics
NPI:1609193887
Name:ROSEBERRY CHIROPRACTIC
Entity Type:Organization
Organization Name:ROSEBERRY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROSEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:712-660-0997
Mailing Address - Street 1:1000 LAKE SAINT LOUIS BLVD
Mailing Address - Street 2:100
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1340
Mailing Address - Country:US
Mailing Address - Phone:636-695-4570
Mailing Address - Fax:
Practice Address - Street 1:2551 BREDELL AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MO
Practice Address - Zip Code:63143-1807
Practice Address - Country:US
Practice Address - Phone:712-660-0997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009038320261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty