Provider Demographics
NPI:1790977122
Name:WEST END CHIROPRACTIC & REHAB CENTER
Entity Type:Organization
Organization Name:WEST END CHIROPRACTIC & REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:GERDINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-631-4650
Mailing Address - Street 1:305 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1229
Mailing Address - Country:US
Mailing Address - Phone:314-361-4650
Mailing Address - Fax:314-361-4663
Practice Address - Street 1:305 UNION BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1229
Practice Address - Country:US
Practice Address - Phone:314-361-4650
Practice Address - Fax:314-361-4663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000149199111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO164713OtherBLUE CROSS GROUP NUMBER