MEDICARE: CRESTWOOD BACK AND NECK PAIN CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1194169334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESTWOOD BACK AND NECK PAIN CLINIC

Provider Business Mailing Address
First Line	:	9109 WATSON RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-2235
Country	:	US
Telephone Number	:	314-961-4101
Fax Number	:

Provider Business Practice Location Address
First Line	:	9109 WATSON RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-2235
Country	:	US
Telephone Number	:	314-961-4101
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NICK CALANDRO
Credential	:
Telephone Number	:	314-961-4101

Provider Enumeration Date	:	04/18/2013
Last Update Date	:	04/18/2013

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