Provider Demographics
NPI:1881961829
Name:CHIROPRACTIC AND SPORTS REHAB
Entity type:Organization
Organization Name:CHIROPRACTIC AND SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-372-6702
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63302-0385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 BROOKES DR
Practice Address - Street 2:SUITE 237
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-2736
Practice Address - Country:US
Practice Address - Phone:314-372-6702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010040254302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization