Provider Demographics
NPI:1649296583
Name:KINESIOLOGY CENTER OF GREATER ST LOUIS INC
Entity type:Organization
Organization Name:KINESIOLOGY CENTER OF GREATER ST LOUIS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHARINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONABLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-991-5655
Mailing Address - Street 1:8229 CLAYTON RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1155
Mailing Address - Country:US
Mailing Address - Phone:314-991-5655
Mailing Address - Fax:314-532-5080
Practice Address - Street 1:608 NO MCKNIGHT RD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-4911
Practice Address - Country:US
Practice Address - Phone:314-991-5655
Practice Address - Fax:314-991-4872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO3930111N00000X
111N00000X
MO2086111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
178246OtherHEALTHLINK
350045267OtherRAILROAD MEDICARE
7412OtherBLUE CROSS BS OF MO
10315XOtherEMPIRE BLUE CROSS
4582036OtherAETNA
084723OtherHEALTH ALLIANCE
179148OtherHEALTHLINK
57883OtherGROUP HEALTH PLAN
990001765OtherRR MEDICARE GROUP PIN
4327678OtherAETNA
3930OtherMISSOURI LICENSE
10146XOtherEMPIRE BLUE CROSS
10146XOtherEMPIRE BLUE CROSS
57883OtherGROUP HEALTH PLAN
4327678OtherAETNA
4582036OtherAETNA
179148OtherHEALTHLINK
000032176Medicare ID - Type Unspecified
178246OtherHEALTHLINK
2086Medicare ID - Type UnspecifiedMISSOURI LICENSE BERT T H