MEDICARE: DR. JOSHUA SHANE CARMON D.C.

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	2010040776	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	38-3832125	OTHER	MO	TAX ID
2	2010040776	OTHER	MO	STATE CHIROPRACTIC LICENSE
3	12192202	OTHER	MO	CAQH
4	1619273257	OTHER	MO	NPI

General Provider Information

NPI Number	:	1619273257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSHUA SHANE CARMON D.C.

Provider Business Mailing Address
First Line	:	5809 S LINDBERGH BLVD
Second Line	:	SUITE B
City	:	SAINT LOUIS
State	:	MO
Zip	:	63123-6948
Country	:	US
Telephone Number	:	314-416-8334
Fax Number	:	314-416-1199

Provider Business Practice Location Address
First Line	:	5809 S LINDBERGH BLVD
Second Line	:	SUITE B
City	:	SAINT LOUIS
State	:	MO
Zip	:	63123-6948
Country	:	US
Telephone Number	:	314-416-8334
Fax Number	:	314-416-1199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2011
Last Update Date	:	01/25/2012

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