Provider Demographics
NPI:1255014304
Name:DYNAMIC CHIROPRACTIC AND REHAB LLC
Entity type:Organization
Organization Name:DYNAMIC CHIROPRACTIC AND REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ACEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-680-2847
Mailing Address - Street 1:122 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 MAIN ST
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1905
Practice Address - Country:US
Practice Address - Phone:314-325-9521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty