Provider Demographics
NPI:1912038308
Name:CRANWELL, RICHARD WAYNE (DC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WAYNE
Last Name:CRANWELL
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 1:11705 GRAVOIS ROAD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127
Mailing Address - Country:US
Mailing Address - Phone:314-843-3039
Mailing Address - Fax:314-843-9604
Practice Address - Street 1:11705 GRAVOIS ROAD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127
Practice Address - Country:US
Practice Address - Phone:314-843-3039
Practice Address - Fax:314-843-9604
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO03791111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000030703Medicare PIN