Provider Demographics
NPI:1922630714
Name:CHIROPRO OF LAKE ST. LOUIS, LLC
Entity Type:Organization
Organization Name:CHIROPRO OF LAKE ST. LOUIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-979-0398
Mailing Address - Street 1:1231 THOUVENOT LN STE 100
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7203
Mailing Address - Country:US
Mailing Address - Phone:618-234-8300
Mailing Address - Fax:618-234-8295
Practice Address - Street 1:6257 RONALD REAGAN DR
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-2665
Practice Address - Country:US
Practice Address - Phone:636-442-0607
Practice Address - Fax:636-625-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty