Provider Demographics
NPI:1689084972
Name:MICHAEL L MASUCCI DC LLC
Entity Type:Organization
Organization Name:MICHAEL L MASUCCI DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LAURENS
Authorized Official - Last Name:MASUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-458-9356
Mailing Address - Street 1:2124 BABLER RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63038-1178
Mailing Address - Country:US
Mailing Address - Phone:636-458-9356
Mailing Address - Fax:
Practice Address - Street 1:2124 BABLER RIDGE LN
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63038-1178
Practice Address - Country:US
Practice Address - Phone:636-458-9356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014013287111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty