Provider Demographics
NPI:1750594552
Name:ERIV A NEPUTE DC LLC
Entity type:Organization
Organization Name:ERIV A NEPUTE DC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-854-3300
Mailing Address - Street 1:110 E 1ST NORTH ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1505
Mailing Address - Country:US
Mailing Address - Phone:217-854-3300
Mailing Address - Fax:217-854-4546
Practice Address - Street 1:4225 BAYLESS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-7513
Practice Address - Country:US
Practice Address - Phone:314-544-5600
Practice Address - Fax:314-544-5696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007000308111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015310Medicare PIN