MEDICARE: KINESIOLOGY CENTER OF GREATER ST LOUIS INC

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	3930	MO
2	111N00000X	Chiropractor

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	350045267	OTHER		RAILROAD MEDICARE
9	990001765	OTHER		RR MEDICARE GROUP PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	178246	OTHER	HEALTHLINK
3	7412	OTHER	BLUE CROSS BS OF MO
4	10315X	OTHER	EMPIRE BLUE CROSS
5	4582036	OTHER	AETNA
6	084723	OTHER	HEALTH ALLIANCE
7	179148	OTHER	HEALTHLINK
8	57883	OTHER	GROUP HEALTH PLAN
10	4327678	OTHER	AETNA
11	3930	OTHER	MISSOURI LICENSE
12	10146X	OTHER	EMPIRE BLUE CROSS

General Provider Information

NPI Number	:	1649296583
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINESIOLOGY CENTER OF GREATER ST LOUIS INC

Provider Business Mailing Address
First Line	:	8229 CLAYTON RD
Second Line	:	SUITE 204
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-1155
Country	:	US
Telephone Number	:	314-991-5655
Fax Number	:	314-532-5080

Provider Business Practice Location Address
First Line	:	608 NO MCKNIGHT RD
Second Line	:
City	:	ST LOUIS
State	:	MO
Zip	:	63132-4911
Country	:	US
Telephone Number	:	314-991-5655
Fax Number	:	314-991-4872

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	KATHARINE M CONABLE
Credential	:	DC
Telephone Number	:	314-991-5655

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	03/27/2014

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Directions to “KINESIOLOGY CENTER OF GREATER ST LOUIS INC ” Practice Location

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