Provider Demographics
NPI:1922121912
Name:FENTON CHIROPRACTIC AND REHAB CENTER, INC
Entity Type:Organization
Organization Name:FENTON CHIROPRACTIC AND REHAB CENTER, INC
Other - Org Name:SPINAL CARE OF ST LOUIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HEIMGARTNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-305-6490
Mailing Address - Street 1:651 GRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-4136
Mailing Address - Country:US
Mailing Address - Phone:636-305-6490
Mailing Address - Fax:636-305-6492
Practice Address - Street 1:651 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-4136
Practice Address - Country:US
Practice Address - Phone:636-305-6490
Practice Address - Fax:636-305-6492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006000760111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00025957Medicare ID - Type Unspecified