Provider Demographics
NPI:1245010743
Name:COSGROVE, JUSTIN (DC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:COSGROVE
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 1:1190 JEFFERSON ST STE 203
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4443
Mailing Address - Country:US
Mailing Address - Phone:636-283-0328
Mailing Address - Fax:
Practice Address - Street 1:1190 JEFFERSON ST STE 203
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4443
Practice Address - Country:US
Practice Address - Phone:636-359-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023039645111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor