Provider Demographics
NPI:1922054188
Name:BURRELL, LARRY EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:EDWARD
Last Name:BURRELL
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 1:4 WEST DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-1793
Mailing Address - Country:US
Mailing Address - Phone:636-536-3622
Mailing Address - Fax:636-536-2039
Practice Address - Street 1:4 WEST DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-1793
Practice Address - Country:US
Practice Address - Phone:636-536-3622
Practice Address - Fax:636-536-2039
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO6502111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU05670Medicare UPIN