Healthcare Provider Details

I. General information

NPI: 1922310382
Provider Name (Legal Business Name): MEGAN RENEE GWINN D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 W MAIN ST
BELLEVILLE IL
62226-5504
US

IV. Provider business mailing address

4401 W MAIN ST
BELLEVILLE IL
62226-5504
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-6260
  • Fax: 618-277-6278
Mailing address:
  • Phone: 618-277-6260
  • Fax: 618-277-6278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038011729
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: