Provider Demographics
NPI:1689975252
Name:NORTH COUNTY REHAB, D.C., LLC
Entity Type:Organization
Organization Name:NORTH COUNTY REHAB, D.C., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:H
Authorized Official - Last Name:UTTERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-551-0000
Mailing Address - Street 1:350C VILLAGE SQUARE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1800
Mailing Address - Country:US
Mailing Address - Phone:314-551-0000
Mailing Address - Fax:
Practice Address - Street 1:350C VILLAGE SQUARE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1800
Practice Address - Country:US
Practice Address - Phone:314-551-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007000279261QM2500X
MOCE006295261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty