Provider Demographics
NPI:1720227549
Name:CHARLESTON SQUARE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:CHARLESTON SQUARE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:QUINN
Authorized Official - Middle Name:J
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-441-9240
Mailing Address - Street 1:4249 N SAINT PETERS PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63304-7441
Mailing Address - Country:US
Mailing Address - Phone:636-441-9240
Mailing Address - Fax:636-441-2224
Practice Address - Street 1:4249 N SAINT PETERS PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63304-7441
Practice Address - Country:US
Practice Address - Phone:636-441-9240
Practice Address - Fax:636-441-2224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000145882111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty