Provider Demographics
NPI:1992836506
Name:WINGHAVEN CHIROPRACTIC PC
Entity Type:Organization
Organization Name:WINGHAVEN CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:STOJEBA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-695-2100
Mailing Address - Street 1:9979 WINGHAVEN BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3627
Mailing Address - Country:US
Mailing Address - Phone:636-695-2100
Mailing Address - Fax:
Practice Address - Street 1:9979 WINGHAVEN BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3627
Practice Address - Country:US
Practice Address - Phone:636-695-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005845111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000032030Medicare PIN
MOU05436Medicare UPIN