Provider Demographics
NPI:1790886919
Name:WOODWARD, BRIAN LEE (DC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:LEE
Last Name:WOODWARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8460 WATSON ROAD
Mailing Address - Street 2:SUITE 124
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-5247
Mailing Address - Country:US
Mailing Address - Phone:314-842-2393
Mailing Address - Fax:314-842-7764
Practice Address - Street 1:8460 WATSON ROAD
Practice Address - Street 2:SUITE 124
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-5247
Practice Address - Country:US
Practice Address - Phone:314-842-2393
Practice Address - Fax:314-842-7764
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO14242OtherBC BS