Provider Demographics
NPI:1942698998
Name:DIVAN CHIROPRACTIC AND SPORTS REHABILITATION
Entity Type:Organization
Organization Name:DIVAN CHIROPRACTIC AND SPORTS REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-961-7181
Mailing Address - Street 1:8045 BIG BEND BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2714
Mailing Address - Country:US
Mailing Address - Phone:314-961-7181
Mailing Address - Fax:
Practice Address - Street 1:8045 BIG BEND BLVD
Practice Address - Street 2:107
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2714
Practice Address - Country:US
Practice Address - Phone:314-961-7181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014010441111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty