Provider Demographics
NPI:1700293644
Name:DR. ROB FAST LLC
Entity Type:Organization
Organization Name:DR. ROB FAST LLC
Other - Org Name:BACK PAIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:FAST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-704-4150
Mailing Address - Street 1:5206 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-4731
Mailing Address - Country:US
Mailing Address - Phone:618-234-5200
Mailing Address - Fax:618-234-4400
Practice Address - Street 1:5206 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-4731
Practice Address - Country:US
Practice Address - Phone:618-234-5200
Practice Address - Fax:618-234-4400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-11
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009109111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty